Provider Demographics
NPI:1508140922
Name:MASHANTUCKET PEQUOT TRIBAL COUNCIL
Entity Type:Organization
Organization Name:MASHANTUCKET PEQUOT TRIBAL COUNCIL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRIBAL HEALTH SERVICES DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANNA
Authorized Official - Middle Name:TARI
Authorized Official - Last Name:REELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-312-8014
Mailing Address - Street 1:PO BOX 3260
Mailing Address - Street 2:75 RT 2
Mailing Address - City:MASHANTUCKET
Mailing Address - State:CT
Mailing Address - Zip Code:06339-3260
Mailing Address - Country:US
Mailing Address - Phone:860-312-8000
Mailing Address - Fax:860-312-8001
Practice Address - Street 1:75 ROUTE 2
Practice Address - Street 2:
Practice Address - City:LEDYARD
Practice Address - State:CT
Practice Address - Zip Code:06339-1128
Practice Address - Country:US
Practice Address - Phone:860-312-8000
Practice Address - Fax:860-312-8001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-04
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty