Provider Demographics
NPI:1699788356
Name:PENOBSCOT INDIAN NATION
Entity type:Organization
Organization Name:PENOBSCOT INDIAN NATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KNOX NICOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-817-7400
Mailing Address - Street 1:23 WABANAKI WAY
Mailing Address - Street 2:
Mailing Address - City:INDIAN ISLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04468-1252
Mailing Address - Country:US
Mailing Address - Phone:207-817-7400
Mailing Address - Fax:207-817-7452
Practice Address - Street 1:23 WABANAKI WAY
Practice Address - Street 2:
Practice Address - City:INDIAN ISLAND
Practice Address - State:ME
Practice Address - Zip Code:04468-1252
Practice Address - Country:US
Practice Address - Phone:207-817-7400
Practice Address - Fax:207-817-7452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPH50000041332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME106520200Medicaid
2036350OtherPK