Basic Information
| Provider Information | |||||||||
| NPI: | 1306481437 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TANANA CHIEFS CONFERENCE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 122 1ST AVE STE 106 | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997014871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074528251 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1717 W COWLES ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997015926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074516682 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2019 | ||||||||
| LastUpdateDate: | 11/13/2019 | ||||||||
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| AuthorizedOfficialLastName: | BERGSTROM | ||||||||
| AuthorizedOfficialFirstName: | JACOLINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EX. DIRECTOR OF H.S. | ||||||||
| AuthorizedOfficialTelephone: | 9074528251 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TANANA CHIEFS CONFENERCE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.