Provider Demographics
NPI:1467442863
Name:MOHEGAN TRIBE OF INDIANS OF CONNECTICUT
Entity type:Organization
Organization Name:MOHEGAN TRIBE OF INDIANS OF CONNECTICUT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:T
Authorized Official - Last Name:GENTILE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-257-9201
Mailing Address - Street 1:PO BOX 290184
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06129-0184
Mailing Address - Country:US
Mailing Address - Phone:860-257-9201
Mailing Address - Fax:860-721-6360
Practice Address - Street 1:13 CROW HILL RD
Practice Address - Street 2:
Practice Address - City:UNCASVILLE
Practice Address - State:CT
Practice Address - Zip Code:06382-1118
Practice Address - Country:US
Practice Address - Phone:860-862-6110
Practice Address - Fax:860-862-6140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
C086P1341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004185428Medicaid
590012782OtherRAILROAD MEDICARE
CT590000180Medicare PIN