1417047689 NPI number — FALL MOUNTAIN PHYSICAL THERAPY AND ATHLETIC TRAINING, PLLC

Table of content: (NPI 1417047689)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417047689 NPI number — FALL MOUNTAIN PHYSICAL THERAPY AND ATHLETIC TRAINING, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FALL MOUNTAIN PHYSICAL THERAPY AND ATHLETIC TRAINING, PLLC
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:
FMPTAT
Provider Other Organization Name Type Code:
5
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:
1417047689
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 57
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALSTEAD
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03602-0057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-835-7828
Provider Business Mailing Address Fax Number:
603-835-7827

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
122 NH ROUTE 12A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANGDON
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03602-8221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-835-7828
Provider Business Practice Location Address Fax Number:
603-835-7827
Provider Enumeration Date:
10/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
YOUNG
Authorized Official First Name:
LISA
Authorized Official Middle Name:
N
Authorized Official Title or Position:
OWNER, PT, ATC
Authorized Official Telephone Number:
603-835-7828

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2994 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2255A2300X , with the licence number: 0036 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: AA65774 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 6007380 . This is a "MVP" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 08Y007675NH03 . This is a "ANTHEM BCBS" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 30394477 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: DF1145 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".




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