Provider Demographics
NPI:1508170556
Name:MASHANTUCKET PEQUOT TRIBAL NATION HEALTH CENTER
Entity Type:Organization
Organization Name:MASHANTUCKET PEQUOT TRIBAL NATION HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRIBAL COUNCIL CHAIRMAN
Authorized Official - Prefix:MR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-396-6133
Mailing Address - Street 1:75 ROUTE 2
Mailing Address - Street 2:PO BOX 3260
Mailing Address - City:MASHANTUCKET
Mailing Address - State:CT
Mailing Address - Zip Code:06338-3260
Mailing Address - Country:US
Mailing Address - Phone:860-321-8000
Mailing Address - Fax:860-312-4883
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:860-321-8000
Practice Address - Fax:860-321-4883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-02
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center