Provider Demographics
NPI:1891856894
Name:BRISTOL BAY AREA HEALTH CORPORATION
Entity Type:Organization
Organization Name:BRISTOL BAY AREA HEALTH CORPORATION
Other - Org Name:KING SALMON
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-842-5201
Mailing Address - Street 1:6000 KANAKANAK RD
Mailing Address - Street 2:
Mailing Address - City:DILLINGHAM
Mailing Address - State:AK
Mailing Address - Zip Code:99576
Mailing Address - Country:US
Mailing Address - Phone:907-842-5201
Mailing Address - Fax:907-842-9250
Practice Address - Street 1:357 MAIN STREET
Practice Address - Street 2:
Practice Address - City:KING SALMON
Practice Address - State:AK
Practice Address - Zip Code:99613-0000
Practice Address - Country:US
Practice Address - Phone:907-842-5201
Practice Address - Fax:907-842-9250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK920044692261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TEZ022Medicare ID - Type UnspecifiedMEDICARE FACILITY #