Provider Demographics
NPI:1982877353
Name:OLD MINTO FAMILY RECOVERY CAMP
Entity Type:Organization
Organization Name:OLD MINTO FAMILY RECOVERY CAMP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH SERVICES DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-452-8251
Mailing Address - Street 1:122 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:122 1ST AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4803
Practice Address - Country:US
Practice Address - Phone:907-452-8251
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TANANA CHIEFS CONFERENCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK246135324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDA4380Medicaid