Healthcare Provider Details

I. General information

NPI: 1508140922
Provider Name (Legal Business Name): MASHANTUCKET PEQUOT TRIBAL COUNCIL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2011
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 ROUTE 2
LEDYARD CT
06339-1128
US

IV. Provider business mailing address

PO BOX 3260 75 RT 2
MASHANTUCKET CT
06339-3260
US

V. Phone/Fax

Practice location:
  • Phone: 860-312-8000
  • Fax: 860-312-8001
Mailing address:
  • Phone: 860-312-8000
  • Fax: 860-312-8001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SHANNA TARI REELS
Title or Position: TRIBAL HEALTH SERVICES DIRECTOR
Credential:
Phone: 860-312-8014