Provider Demographics
NPI:1952304271
Name:TOK COMMUNITY CLINIC, INCORPORATED
Entity Type:Organization
Organization Name:TOK COMMUNITY CLINIC, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:LE ROY
Authorized Official - Last Name:RUTLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-883-5873
Mailing Address - Street 1:PO BOX 33
Mailing Address - Street 2:
Mailing Address - City:TOK
Mailing Address - State:AK
Mailing Address - Zip Code:99780-0033
Mailing Address - Country:US
Mailing Address - Phone:907-883-5873
Mailing Address - Fax:907-883-3640
Practice Address - Street 1:MILE 124 TOK CUTOFF
Practice Address - Street 2:
Practice Address - City:TOK
Practice Address - State:AK
Practice Address - Zip Code:99780-0033
Practice Address - Country:US
Practice Address - Phone:907-883-5873
Practice Address - Fax:907-883-3640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK6185341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKGA6185Medicaid
AK0000RGBMKMedicare ID - Type UnspecifiedAMBULANCE SERVICE