Basic Information
| Provider Information | |||||||||
| NPI: | 1023108354 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LRGHEALTHCARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | NEWFOUND FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1327 | ||||||||
| Address2: | |||||||||
| City: | LACONIA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 032471327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035243211 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5 SCHOOL ST | ||||||||
| Address2: | |||||||||
| City: | BRISTOL | ||||||||
| State: | NH | ||||||||
| PostalCode: | 032223263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037445441 | ||||||||
| FaxNumber: | 6037443698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 06/05/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DONOVAN | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 6035243211 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LRGHEALTHCARE | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | NH | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | LRGH703507 | 01 | NH | ANTHEM | OTHER | 59780 | 01 | NH | CIGNA | OTHER | 3080972 | 05 | NH | MEDICAID |