Provider Demographics
NPI:1851662233
Name:GIRDWOOD HEALTH CLINIC, INC.
Entity Type:Organization
Organization Name:GIRDWOOD HEALTH CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-783-1355
Mailing Address - Street 1:PO BOX 1130
Mailing Address - Street 2:
Mailing Address - City:GIRDWOOD
Mailing Address - State:AK
Mailing Address - Zip Code:99587-1130
Mailing Address - Country:US
Mailing Address - Phone:907-783-1355
Mailing Address - Fax:907-783-1357
Practice Address - Street 1:131 LINDBLAD AVENUE
Practice Address - Street 2:
Practice Address - City:GIRDWOOD
Practice Address - State:AK
Practice Address - Zip Code:99587
Practice Address - Country:US
Practice Address - Phone:907-783-1355
Practice Address - Fax:907-783-1357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-18
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK261QC1500X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK6742520001Medicare NSC