Healthcare Provider Details

I. General information

NPI: 1023187721
Provider Name (Legal Business Name): WAMPANOAG TRIBE OF GAY HEAD AQUINNAH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 BLACK BROOK RD
AQUINNAH MA
02535-1546
US

IV. Provider business mailing address

20 BLACK BROOK RD
AQUINNAH MA
02535-1546
US

V. Phone/Fax

Practice location:
  • Phone: 508-645-9265
  • Fax: 508-645-2922
Mailing address:
  • Phone: 508-645-9265
  • Fax: 508-645-2922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateMA

VIII. Authorized Official

Name: MR. RON MACLAREN
Title or Position: HEALTH DIRECTOR
Credential:
Phone: 508-645-9265