Provider Demographics
NPI:1760474613
Name:PASSAMAQUODDY TRIBAL COUNCIL
Entity Type:Organization
Organization Name:PASSAMAQUODDY TRIBAL COUNCIL
Other - Org Name:PLEASANT POINT HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMIN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:BORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-853-0555
Mailing Address - Street 1:PO BOX 351
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:ME
Mailing Address - Zip Code:04667-0351
Mailing Address - Country:US
Mailing Address - Phone:207-853-0644
Mailing Address - Fax:207-853-2347
Practice Address - Street 1:11 BACK RD
Practice Address - Street 2:
Practice Address - City:PLEASANT POINT
Practice Address - State:ME
Practice Address - Zip Code:04667-4119
Practice Address - Country:US
Practice Address - Phone:207-853-0644
Practice Address - Fax:207-853-2347
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PASSAMAQUODDY TRIBAL COUNCIL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-17
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME107300000Medicaid
ME107300100Medicaid
ME107300200Medicaid
ME107300000Medicaid
ME107300100Medicaid