Healthcare Provider Details

I. General information

NPI: 1750969168
Provider Name (Legal Business Name): UPPER MATTAPONI INDIAN TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7864 RICHMOND TAPPAHANNOCK HWY
AYLETT VA
23009-3056
US

IV. Provider business mailing address

13476 KING WILLIAM RD
KING WILLIAM VA
23086-3401
US

V. Phone/Fax

Practice location:
  • Phone: 804-769-2015
  • Fax:
Mailing address:
  • Phone: 804-769-0041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: STEVEN FAMILY TUPPONCE
Title or Position: DIRECTOR
Credential:
Phone: 804-347-4109