1124344999 NPI number — DAVID BEAUFAIT

Table of content: BENJAMIN VAN LEEUWEN MD (NPI 1942734785)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124344999 NPI number — DAVID BEAUFAIT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID BEAUFAIT
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:
Provider Other Organization Name Type Code:
6
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:
1124344999
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
411 US ROUTE 4
Provider Second Line Business Mailing Address:
PO BOX 669
Provider Business Mailing Address City Name:
ENFIELD
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03748-3168
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-632-5600
Provider Business Mailing Address Fax Number:
603-632-5477

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
411 US ROUTE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENFIELD
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03748-3168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-632-5600
Provider Business Practice Location Address Fax Number:
603-632-5477
Provider Enumeration Date:
04/19/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BEAUFAIT
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
603-632-5600

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  6754 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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