Provider Demographics
NPI:1295972677
Name:KENAITZE INDIAN TRIBE
Entity type:Organization
Organization Name:KENAITZE INDIAN TRIBE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-335-7200
Mailing Address - Street 1:PO BOX 988
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-0988
Mailing Address - Country:US
Mailing Address - Phone:907-335-7500
Mailing Address - Fax:907-335-2155
Practice Address - Street 1:508 UPLAND ST
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-8026
Practice Address - Country:US
Practice Address - Phone:907-335-7500
Practice Address - Fax:907-335-2155
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENAITZE INDIAN TRIBE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-07
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332800000X, 261QD0000X, 261QF0400X
AKIHS122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) PharmacyGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK021855OtherFQHC CERTIFICATION NUMBER
AKDDG020Medicaid