Provider Demographics
NPI:1134258247
Name:OLGA IRIS WASILE
Entity type:Organization
Organization Name:OLGA IRIS WASILE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:E
Authorized Official - Last Name:HODGES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-688-0901
Mailing Address - Street 1:PO BOX 671249
Mailing Address - Street 2:
Mailing Address - City:CHUGIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99567-1249
Mailing Address - Country:US
Mailing Address - Phone:907-688-0901
Mailing Address - Fax:907-688-0830
Practice Address - Street 1:20905 EASTSIDE DR #1
Practice Address - Street 2:
Practice Address - City:CHUGIAK
Practice Address - State:AK
Practice Address - Zip Code:99567-1249
Practice Address - Country:US
Practice Address - Phone:907-688-0901
Practice Address - Fax:907-688-0830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD57672Medicaid
AK4987OtherOCCUPATIONAL LICENSE
AK1306952569OtherWASILE NPI
AKMD57672Medicaid