Provider Demographics
NPI:1790377588
Name:FAIRBANKS COMMUNITY MENTAL HEALTH SERVICES
Entity Type:Organization
Organization Name:FAIRBANKS COMMUNITY MENTAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:EVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-261-5317
Mailing Address - Street 1:4020 FOLKER ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5321
Mailing Address - Country:US
Mailing Address - Phone:907-563-1000
Mailing Address - Fax:907-375-3142
Practice Address - Street 1:926 ASPEN ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-5501
Practice Address - Country:US
Practice Address - Phone:907-371-1300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1596091Medicaid