Provider Demographics
NPI:1023187721
Name:WAMPANOAG TRIBE OF GAY HEAD AQUINNAH
Entity Type:Organization
Organization Name:WAMPANOAG TRIBE OF GAY HEAD AQUINNAH
Other - Org Name:WAMPANOAG HEALTH SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:MACLAREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-645-9265
Mailing Address - Street 1:20 BLACK BROOK RD
Mailing Address - Street 2:
Mailing Address - City:AQUINNAH
Mailing Address - State:MA
Mailing Address - Zip Code:02535-1546
Mailing Address - Country:US
Mailing Address - Phone:508-645-9265
Mailing Address - Fax:508-645-2922
Practice Address - Street 1:20 BLACK BROOK RD
Practice Address - Street 2:
Practice Address - City:AQUINNAH
Practice Address - State:MA
Practice Address - Zip Code:02535-1546
Practice Address - Country:US
Practice Address - Phone:508-645-9265
Practice Address - Fax:508-645-2922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM17601OtherBLUE CROSS BLUE SHIELD
MA1312197Medicaid
MAM17601OtherBLUE CROSS BLUE SHIELD