Provider Demographics
NPI:1689925463
Name:NATIVE VILLAGE OF TYONEK
Entity Type:Organization
Organization Name:NATIVE VILLAGE OF TYONEK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRIBAL ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-583-2201
Mailing Address - Street 1:PO BOX 82009
Mailing Address - Street 2:
Mailing Address - City:TYONEK
Mailing Address - State:AK
Mailing Address - Zip Code:99682-0009
Mailing Address - Country:US
Mailing Address - Phone:907-583-2461
Mailing Address - Fax:907-583-2155
Practice Address - Street 1:73 C STREET
Practice Address - Street 2:
Practice Address - City:TYONEK
Practice Address - State:AK
Practice Address - Zip Code:99682
Practice Address - Country:US
Practice Address - Phone:907-583-2461
Practice Address - Fax:907-583-2155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK261Q00000X261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center