Provider Demographics
NPI:1396097614
Name:BRISTOL BAY AREA HEALTH CORPORATION
Entity type:Organization
Organization Name:BRISTOL BAY AREA HEALTH CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:LEEANN
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-842-5201
Mailing Address - Street 1:P.O. BOX 36
Mailing Address - Street 2:
Mailing Address - City:CHIGNIK LAKE
Mailing Address - State:AK
Mailing Address - Zip Code:99548
Mailing Address - Country:US
Mailing Address - Phone:907-845-2236
Mailing Address - Fax:907-845-2353
Practice Address - Street 1:36 ALDER DR.
Practice Address - Street 2:
Practice Address - City:CHIGNIK LAKE
Practice Address - State:AK
Practice Address - Zip Code:99548-0036
Practice Address - Country:US
Practice Address - Phone:907-845-2236
Practice Address - Fax:907-845-2353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-10
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1114050911Medicaid