1801174586 NPI number — FAMILY DIABETES CLINIC

Table of content: (NPI 1801174586)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801174586 NPI number — FAMILY DIABETES CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY DIABETES CLINIC
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:
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:
1801174586
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1407 W 31ST AVE
Provider Second Line Business Mailing Address:
STE. 200
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99503-3678
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-677-3750
Provider Business Mailing Address Fax Number:
907-677-3751

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1407 W 31ST AVE
Provider Second Line Business Practice Location Address:
STE. 600
Provider Business Practice Location Address City Name:
ANCHORAGE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99503-3678
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-677-3750
Provider Business Practice Location Address Fax Number:
907-677-3751
Provider Enumeration Date:
07/28/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MICHALSKI
Authorized Official First Name:
TRACY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
907-677-3750

Provider Taxonomy Codes

  • Taxonomy code: 364SF0001X , with the licence number:  688 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MPG0391 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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