Basic Information
| Provider Information | |||||||||
| NPI: | 1730532177 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEANFAVRE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 73 NEWTON RD | ||||||||
| Address2: | STE 101 | ||||||||
| City: | PLAISTOW | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038652424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9783887272 | ||||||||
| FaxNumber: | 9783887373 | ||||||||
| Practice Location | |||||||||
| Address1: | 607 BANTAM RD | ||||||||
| Address2: | UNIT H | ||||||||
| City: | BANTAM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067501634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605677787 | ||||||||
| FaxNumber: | 8605677779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2016 | ||||||||
| LastUpdateDate: | 07/21/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 10999 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.