Basic Information
| Provider Information | |||||||||
| NPI: | 1396832580 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THI OF NEW HAMPSHIRE AT DERRY, LLC | ||||||||
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| OtherOrganizationName: | PLEASANT VALLEY NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 920 RIDGEBROOK RD | ||||||||
| Address2: | |||||||||
| City: | SPARKS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211529390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107731000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8 PEABODY RD | ||||||||
| Address2: | |||||||||
| City: | DERRY | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030381807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034341566 | ||||||||
| FaxNumber: | 6034342299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2006 | ||||||||
| LastUpdateDate: | 06/29/2011 | ||||||||
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| AuthorizedOfficialLastName: | ST. CYR | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6034341566 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 30102629 | 05 | NH | MEDICAID |