Provider Demographics
NPI:1811199169
Name:MANIILAQ ASSOCIATION
Entity Type:Organization
Organization Name:MANIILAQ ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:SOURS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-442-7582
Mailing Address - Street 1:PO BOX 256
Mailing Address - Street 2:
Mailing Address - City:KOTZEBUE
Mailing Address - State:AK
Mailing Address - Zip Code:99752-0256
Mailing Address - Country:US
Mailing Address - Phone:907-442-3311
Mailing Address - Fax:
Practice Address - Street 1:572 FRIENDS WAY
Practice Address - Street 2:
Practice Address - City:KOTZEBUE
Practice Address - State:AK
Practice Address - Zip Code:99752
Practice Address - Country:US
Practice Address - Phone:907-442-7582
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK400278322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKBR0023Medicaid