# KODIAK ISLAND AMBULATORY CARE CLINIC INC.

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1366596504
- **Authorized official:** JOHN M. KOLLER M.D. (PRESIDENT)
- **Authorized official phone:** (907) 486-6188

## Contact information

- **Practice address:** 202 CENTER AVE, STE. 102, KODIAK, AK 99615-1126
- **Practice address phone:** (907) 486-6188
- **Practice address fax:** (907) 486-6146
- **Mailing address:** PO BOX 1126, KODIAK, AK 99615-1126
- **Mailing address phone:** (907) 486-6188
- **Mailing address fax:** (907) 486-6146

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QU0200X | Urgent Care Clinic/Center | DL282350 | AK | Yes |

## Other

- **Enumeration date:** 01/23/2007
- **Last updated:** 05/16/2011

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 02D0985615 | CLIA NUMBER | AK |
| 01 | — | 6270850001 | MEDICARE DME | — |
| 01 | — | DL282350 | BUSINESS LICENSE NUMBER | AK |
| 01 | — | K162500 | MEDICARE PTAN | — |
| 05 | — | MD10072 | — | AK |