Basic Information
Provider Information
NPI: 1033557509
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: O'DOMIN
FirstName: OLAF
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 6000 KANAKANAK RD
Address2:  
City: DILLINGHAM
State: AK
PostalCode: 995760130
CountryCode: US
TelephoneNumber: 9078429217
FaxNumber: 9078429250
Practice Location
Address1: 6000 KANAKANAK RD
Address2:  
City: DILLINGHAM
State: AK
PostalCode: 995760130
CountryCode: US
TelephoneNumber: 9078429217
FaxNumber: 9078429250
Other Information
ProviderEnumerationDate: 06/06/2013
LastUpdateDate: 06/06/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
172V00000X12-1208-IIIAKY Other Service ProvidersCommunity Health Worker 

No ID Information.


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