Provider Demographics
NPI:1063602563
Name:MYRA ROBERTS CLINIC
Entity type:Organization
Organization Name:MYRA ROBERTS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-662-7529
Mailing Address - Street 1:P.O. BOX 81060
Mailing Address - Street 2:
Mailing Address - City:VENETIE
Mailing Address - State:AK
Mailing Address - Zip Code:99740-0060
Mailing Address - Country:US
Mailing Address - Phone:907-849-8712
Mailing Address - Fax:907-849-8915
Practice Address - Street 1:81060 MAIN STREET
Practice Address - Street 2:
Practice Address - City:VENETIE
Practice Address - State:AK
Practice Address - Zip Code:99740-0060
Practice Address - Country:US
Practice Address - Phone:907-849-8712
Practice Address - Fax:907-849-8915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center