1306493531 NPI number — MACKENZIE RYAN SEELY LADC

Table of content: MACKENZIE RYAN SEELY LADC (NPI 1306493531)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306493531 NPI number — MACKENZIE RYAN SEELY LADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SEELY
Provider First Name:
MACKENZIE
Provider Middle Name:
RYAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LADC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1306493531
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
122 MARKET ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANCHESTER
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03101-1952
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-641-9441
Provider Business Mailing Address Fax Number:
603-935-8270

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
293 WILSON STREET
Provider Second Line Business Practice Location Address:
3RD FLOOR
Provider Business Practice Location Address City Name:
MANCHESTER
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03103-5021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-641-9441
Provider Business Practice Location Address Fax Number:
603-935-8270
Provider Enumeration Date:
08/22/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  1094 , 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)