Basic Information
| Provider Information | |||||||||
| NPI: | 1003019837 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COOS COUNTY FAMILY HEALTH SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 133 PLEASANT STREET | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037522040 | ||||||||
| FaxNumber: | 6037521709 | ||||||||
| Practice Location | |||||||||
| Address1: | 73 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037522424 | ||||||||
| FaxNumber: | 6037522436 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2007 | ||||||||
| LastUpdateDate: | 11/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | GORDON | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6037523669 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COOS COUNTY FAMILY HEALTH SERVICES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 04258 | NH | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 1223G0001X | 01275 | NH | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 1223G0001X | 1275 | NH | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 30301511 | 05 | NH | MEDICAID |