Provider Demographics
NPI:1457344558
Name:ST REGIS MOHAWK TRIBE
Entity Type:Organization
Organization Name:ST REGIS MOHAWK TRIBE
Other - Org Name:ST REGIS MOHAWK HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TRIBAL CHIEF
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAZORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-358-3141
Mailing Address - Street 1:412 STATE ROUTE 37
Mailing Address - Street 2:
Mailing Address - City:AKWESASNE
Mailing Address - State:NY
Mailing Address - Zip Code:13655-3109
Mailing Address - Country:US
Mailing Address - Phone:518-358-3141
Mailing Address - Fax:518-358-2797
Practice Address - Street 1:412 STATE ROUTE 37
Practice Address - Street 2:
Practice Address - City:AKWESASNE
Practice Address - State:NY
Practice Address - Zip Code:13655-3109
Practice Address - Country:US
Practice Address - Phone:518-358-3141
Practice Address - Fax:518-358-2797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1653200R261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01178234Medicaid
NY00651785Medicaid
NY00651785Medicaid
NY01178234Medicaid