Provider Demographics
NPI:1366526188
Name:PASSAMAQUODDY TRIBAL COUNCIL
Entity type:Organization
Organization Name:PASSAMAQUODDY TRIBAL COUNCIL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HEALTH CENTER DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:ALTVATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-853-5010
Mailing Address - Street 1:PO BOX 351
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:ME
Mailing Address - Zip Code:04667-0351
Mailing Address - Country:US
Mailing Address - Phone:207-853-0644
Mailing Address - Fax:207-853-6230
Practice Address - Street 1:11 BACK RD
Practice Address - Street 2:
Practice Address - City:PLEASANT POINT
Practice Address - State:ME
Practice Address - Zip Code:04667-4119
Practice Address - Country:US
Practice Address - Phone:207-853-0644
Practice Address - Fax:207-853-6230
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PLEASANT POINT HEALTH CENTER PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-25
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPH50000192332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME107300100Medicaid