1508170556 NPI number — MASHANTUCKET PEQUOT TRIBAL NATION HEALTH CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508170556 NPI number — MASHANTUCKET PEQUOT TRIBAL NATION HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MASHANTUCKET PEQUOT TRIBAL NATION HEALTH CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508170556
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75 ROUTE 2
Provider Second Line Business Mailing Address:
PO BOX 3260
Provider Business Mailing Address City Name:
MASHANTUCKET
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06338-3260
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-321-8000
Provider Business Mailing Address Fax Number:
860-312-4883

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 ROUTE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEDYARD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06339-1128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-321-8000
Provider Business Practice Location Address Fax Number:
860-321-4883
Provider Enumeration Date:
08/02/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BUTLER
Authorized Official First Name:
RODNEY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
TRIBAL COUNCIL CHAIRMAN
Authorized Official Telephone Number:
860-396-6133

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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