1285901918 NPI number — MANIILAQ ASSOCIATION

Table of content: TRAKETA LA'SHAWN DILLARD LPC (NPI 1952902595)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285901918 NPI number — MANIILAQ ASSOCIATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MANIILAQ ASSOCIATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285901918
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O.BOX 43
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KOTZEBUE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99752-0043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-442-7150
Provider Business Mailing Address Fax Number:
907-442-7250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1729 QALGI AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PT. HOPE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99766-0049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-368-2234
Provider Business Practice Location Address Fax Number:
907-368-2569
Provider Enumeration Date:
11/23/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HANSEN
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
DEPUTY ADMINISTRATOR
Authorized Official Telephone Number:
907-442-7150

Provider Taxonomy Codes

  • Taxonomy code: 261QP0904X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)