Basic Information
| Provider Information | |||||||||
| NPI: | 1255304234 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTEGRICARE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PORTSMOUTH/DERRY/SALEM HOME HEALTH AND HOSPICE SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9 S CHERRY ST | ||||||||
| Address2: | |||||||||
| City: | WALLINGFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064923537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037416565 | ||||||||
| FaxNumber: | 2032692227 | ||||||||
| Practice Location | |||||||||
| Address1: | 95 BREWERY LN | ||||||||
| Address2: | #11 | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038014994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034360815 | ||||||||
| FaxNumber: | 6034315457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ESTES | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT/CFO | ||||||||
| AuthorizedOfficialTelephone: | 2037416565 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 02654 | NH | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 30590127 | 05 | NH | MEDICAID | 30600126 | 05 | NH | MEDICAID |