Provider Demographics
NPI:1821120486
Name:KETCHIKAN INDIAN CORPORATION
Entity Type:Organization
Organization Name:KETCHIKAN INDIAN CORPORATION
Other - Org Name:KIC TRIBAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RCM
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-228-9254
Mailing Address - Street 1:2960 TONGASS AVE
Mailing Address - Street 2:BUSINESS OFFICE
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-5742
Mailing Address - Country:US
Mailing Address - Phone:907-228-9200
Mailing Address - Fax:800-887-8796
Practice Address - Street 1:2960 TONGASS AVE
Practice Address - Street 2:BUSINESS OFFICE
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5742
Practice Address - Country:US
Practice Address - Phone:907-228-9200
Practice Address - Fax:800-887-8796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK78545183500000X, 251S00000X, 261QD0000X, 261QP2300X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCL2696Medicaid
AKCL2696Medicaid