Organization
KODIAK ISLAND AMBULATORY CARE CLINIC INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JOHN M. KOLLER M.D. (PRESIDENT)
(907) 486-6188
Entity
Organization
Contact information
Practice address
202 CENTER AVE, STE. 102, KODIAK, AK 99615-1126
(907) 486-6188
(907) 486-6146
Mailing address
PO BOX 1126, KODIAK, AK 99615-1126
(907) 486-6188
(907) 486-6146
Taxonomy
Speciality
Code
Description
License number
State
261QU0200X
Urgent Care Clinic/Center
Primary
DL282350
AK
Other
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
Enumeration date
01/23/2007
Last updated
05/16/2011
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