Basic Information
| Provider Information | |||||||||
| NPI: | 1437376209 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMMONOOSUC COMMUNITY HEALTH SERVICES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AMMONOOSUC COMMUNITY HEALTH SERVICES, INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 MOUNT EUSTIS RD | ||||||||
| Address2: | |||||||||
| City: | LITTLETON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035613712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034442464 | ||||||||
| FaxNumber: | 6034443441 | ||||||||
| Practice Location | |||||||||
| Address1: | 79 SWIFTWATER RD | ||||||||
| Address2: | |||||||||
| City: | WOODSVILLE | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037851447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037473740 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 05/09/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | NORRINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6034442464 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMMONOOSUC COMMUNITY HEALTH SERVICES, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 80301805 | 05 | NH | MEDICAID |