Healthcare Provider Details

I. General information

NPI: 1659521052
Provider Name (Legal Business Name): ST REGIS MOHAWK TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 03/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 STATE ROUTE 37
AKWESASNE NY
13655-3109
US

IV. Provider business mailing address

412 STATE ROUTE 37
AKWESASNE NY
13655-3109
US

V. Phone/Fax

Practice location:
  • Phone: 518-358-3141
  • Fax: 518-358-2797
Mailing address:
  • Phone: 518-358-3141
  • Fax: 518-358-2797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number111211393
License Number StateNY

VIII. Authorized Official

Name: DEBORAH TERRANCE
Title or Position: HEALTH DIRECTOR
Credential:
Phone: 518-358-3141