Provider Demographics
NPI:1902077837
Name:CHUGACHMIUT
Entity Type:Organization
Organization Name:CHUGACHMIUT
Other - Org Name:ANESIA ANAHONAK MOONIN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH SERVICES DIVISION DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-334-0148
Mailing Address - Street 1:1840 BRAGAW ST STE 110
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-3463
Mailing Address - Country:US
Mailing Address - Phone:907-562-4155
Mailing Address - Fax:
Practice Address - Street 1:63998 GRAHAM ROAD UNIT #3
Practice Address - Street 2:
Practice Address - City:PORT GRAHAM
Practice Address - State:AK
Practice Address - Zip Code:99603
Practice Address - Country:US
Practice Address - Phone:907-284-2241
Practice Address - Fax:907-284-2277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1581154Medicaid