Basic Information
Provider Information | |||||||||
NPI: | 1396292751 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BRISTOL BAY AREA HEALTH CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KANAKANAK HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6000 KANAKANAK RD. | ||||||||
Address2: |   | ||||||||
City: | DILLINGHAM | ||||||||
State: | AK | ||||||||
PostalCode: | 995760130 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9078425201 | ||||||||
FaxNumber: | 9078429250 | ||||||||
Practice Location | |||||||||
Address1: | 6000 KANAKANAK RD. | ||||||||
Address2: |   | ||||||||
City: | DILLINGHAM | ||||||||
State: | AK | ||||||||
PostalCode: | 995760130 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9078425201 | ||||||||
FaxNumber: | 9078429250 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/02/2016 | ||||||||
LastUpdateDate: | 09/02/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CLARK | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9078425201 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332S00000X | 66211 | AK | Y |   | Suppliers | Hearing Aid Equipment |   |
No ID Information.