Provider Demographics
NPI:1043533946
Name:KIC TRIBAL HEALTH CLINIC
Entity type:Organization
Organization Name:KIC TRIBAL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIABETES COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARSHA
Authorized Official - Middle Name:M
Authorized Official - Last Name:RAMIREZ
Authorized Official - Suffix:
Authorized Official - Credentials:CNA
Authorized Official - Phone:907-228-4900
Mailing Address - Street 1:2960 TONGASS AVE
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-5742
Mailing Address - Country:US
Mailing Address - Phone:907-228-4900
Mailing Address - Fax:907-228-4905
Practice Address - Street 1:2960 TONGASS AVE
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5742
Practice Address - Country:US
Practice Address - Phone:907-228-4900
Practice Address - Fax:907-228-4905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-05
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK10728261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)