Provider Demographics
NPI:1053883595
Name:MOOSE CREEK MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:MOOSE CREEK MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADVANCED NURSE PRACTITIONER, BUSINE
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLI
Authorized Official - Middle Name:RAYE
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:ANP
Authorized Official - Phone:907-373-3335
Mailing Address - Street 1:2341 S. FERN ST., SUITE 300
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654
Mailing Address - Country:US
Mailing Address - Phone:907-373-3335
Mailing Address - Fax:907-373-3331
Practice Address - Street 1:2341 S. FERN ST., SUITE 300
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654
Practice Address - Country:US
Practice Address - Phone:907-373-3335
Practice Address - Fax:907-373-3331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-21
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1022256Medicaid