Provider Demographics
NPI:1912079088
Name:FAIRBANKS RESOURCE AGENCY INC
Entity type:Organization
Organization Name:FAIRBANKS RESOURCE AGENCY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:ENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-456-8901
Mailing Address - Street 1:805 AIRPORT ROAD
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701
Mailing Address - Country:US
Mailing Address - Phone:907-456-8901
Mailing Address - Fax:907-452-5171
Practice Address - Street 1:805 AIRPORT ROAD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701
Practice Address - Country:US
Practice Address - Phone:907-456-8901
Practice Address - Fax:907-452-5171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKHC5250Medicaid