Provider Demographics
NPI:1205883907
Name:KODIAK AREA NATIVE ASSOCIATION
Entity type:Organization
Organization Name:KODIAK AREA NATIVE ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:PFEFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-486-9800
Mailing Address - Street 1:3449 E REZANOF DR
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6952
Mailing Address - Country:US
Mailing Address - Phone:907-486-9800
Mailing Address - Fax:907-486-9897
Practice Address - Street 1:3449 E REZANOF DR
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6952
Practice Address - Country:US
Practice Address - Phone:907-486-9800
Practice Address - Fax:907-486-9897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QC1500X
AK233103261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1003903Medicaid