Provider Demographics
NPI:1922559558
Name:TANANA VALLEY CLINIC LLC
Entity Type:Organization
Organization Name:TANANA VALLEY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:G
Authorized Official - Last Name:SUDDUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-458-5300
Mailing Address - Street 1:PO BOX 73720
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-3720
Mailing Address - Country:US
Mailing Address - Phone:907-459-3500
Mailing Address - Fax:907-459-3526
Practice Address - Street 1:1001 NOBLE ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4948
Practice Address - Country:US
Practice Address - Phone:907-459-3500
Practice Address - Fax:907-459-3526
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOUNDATION HEALTH LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-19
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1043161261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1680751Medicaid
AK1740002Medicaid
AK1656211Medicaid
AK1656231Medicaid
AK1656237Medicaid
AK1656211Medicaid