Provider Demographics
NPI:1134523855
Name:COTTONWOOD CREEK CLINIC LLC
Entity type:Organization
Organization Name:COTTONWOOD CREEK CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-373-5950
Mailing Address - Street 1:3600 E WICKERSHAM WAY
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7550
Mailing Address - Country:US
Mailing Address - Phone:907-373-5950
Mailing Address - Fax:907-373-5954
Practice Address - Street 1:3600 E WICKERSHAM WAY
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7550
Practice Address - Country:US
Practice Address - Phone:907-373-5950
Practice Address - Fax:907-373-5954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1011473207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMB0593726OtherDEA NUMBER