Basic Information
| Provider Information | |||||||||
| NPI: | 1891856894 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRISTOL BAY AREA HEALTH CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KING SALMON | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6000 KANAKANAK RD | ||||||||
| Address2: | |||||||||
| City: | DILLINGHAM | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9078425201 | ||||||||
| FaxNumber: | 9078429250 | ||||||||
| Practice Location | |||||||||
| Address1: | MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | KING SALMON | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996130000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9078425201 | ||||||||
| FaxNumber: | 9078429250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 03/25/2013 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9078425201 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 920044692 | AK | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.