Provider Demographics
NPI:1720064884
Name:INTEGRATED SUPPORT COMMAND KODIAK
Entity Type:Organization
Organization Name:INTEGRATED SUPPORT COMMAND KODIAK
Other - Org Name:ROCKMORE-KING CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:LANE
Authorized Official - Last Name:EMERSON
Authorized Official - Suffix:
Authorized Official - Credentials:CLINIC ADMINISTRATOR
Authorized Official - Phone:907-487-5757
Mailing Address - Street 1:BUILDING N 46 CAPE SARLCHEF
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99619-5002
Mailing Address - Country:US
Mailing Address - Phone:907-487-5757
Mailing Address - Fax:907-487-5360
Practice Address - Street 1:BUILDING N46 CAPE SARICHEF
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99619-5002
Practice Address - Country:US
Practice Address - Phone:907-487-5757
Practice Address - Fax:907-487-5360
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:US COAST GUARD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-21
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK261Q00000X, 261QD0000X
AK02D0666660291900000X
AKNCPDP0202414332000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No291900000XLaboratoriesMilitary Clinical Medical Laboratory
No332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy