Provider Demographics
NPI:1285948877
Name:HSWL FO KODIAK DET KETCHIKAN
Entity type:Organization
Organization Name:HSWL FO KODIAK DET KETCHIKAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-228-0320
Mailing Address - Street 1:1300 STEDMAN ST
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-6661
Mailing Address - Country:US
Mailing Address - Phone:907-228-0320
Mailing Address - Fax:907-228-0255
Practice Address - Street 1:1300 STEDMAN ST
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-6661
Practice Address - Country:US
Practice Address - Phone:907-228-0320
Practice Address - Fax:907-228-0255
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:U.S. COAST GUARD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-06
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1101XAmbulatory Health Care FacilitiesClinic/CenterMilitary and U.S. Coast Guard Ambulatory Procedure
No332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy