Provider Demographics
NPI:1194261594
Name:SOUTHEAST ALASKA REGIONAL HEALTH CONSORTIUM
Entity type:Organization
Organization Name:SOUTHEAST ALASKA REGIONAL HEALTH CONSORTIUM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-463-4000
Mailing Address - Street 1:3100 CHANNEL DRIVE STE 300
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801
Mailing Address - Country:US
Mailing Address - Phone:907-463-4000
Mailing Address - Fax:907-463-1510
Practice Address - Street 1:225 FRONT STREET
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801
Practice Address - Country:US
Practice Address - Phone:907-586-4230
Practice Address - Fax:907-586-4237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-10
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK70206251S00000X
261Q00000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No251S00000XAgenciesCommunity/Behavioral Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1662851Medicaid
AK1684455Medicaid
AK70206OtherBUSINESS LICENSE