1295875383 NPI number — LACONIA EYE ASSOCIATES PA

Table of content: (NPI 1295875383)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295875383 NPI number — LACONIA EYE ASSOCIATES PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LACONIA EYE ASSOCIATES PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DBA: LACONIA EYE & LASER CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295875383
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7625
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GILFORD
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03247-7625
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-528-2606
Provider Business Mailing Address Fax Number:
603-528-2805

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
368 HOUNSELL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GILFORD
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03249-6922
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-528-2606
Provider Business Practice Location Address Fax Number:
603-528-2805
Provider Enumeration Date:
02/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SCOTT
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
603-528-2606

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  832 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 10993 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 8400 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 30212353 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




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