Basic Information
Provider Information | |||||||||
NPI: | 1912166380 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AMMONOOSUC COMMUNITY HEALTH SERVICES INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 25 MOUNT EUSTIS RD | ||||||||
Address2: |   | ||||||||
City: | LITTLETON | ||||||||
State: | NH | ||||||||
PostalCode: | 035613712 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6034442464 | ||||||||
FaxNumber: | 6034443441 | ||||||||
Practice Location | |||||||||
Address1: | 25 MOUNT EUSTIS RD | ||||||||
Address2: |   | ||||||||
City: | LITTLETON | ||||||||
State: | NH | ||||||||
PostalCode: | 035613712 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6034442464 | ||||||||
FaxNumber: | 6034443441 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2008 | ||||||||
LastUpdateDate: | 07/01/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WILLIAMS | ||||||||
AuthorizedOfficialFirstName: | NORRINE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 6034442464 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | AMMONOOSUC COMMUNITY HEALTH SERVICES, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0050X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Family Planning, Non-Surgical |
ID Information
ID | Type | State | Issuer | Description | 30546573 | 05 | NH |   | MEDICAID |