1720961865 NPI number — WILD PRAIRIE PRIMARY CARE PLLC

Table of content: (NPI 1720961865)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720961865 NPI number — WILD PRAIRIE PRIMARY CARE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILD PRAIRIE PRIMARY CARE 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:
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:
1720961865
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/28/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
240 MECHANIC ST STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03766-2617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
240 MECHANIC ST STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03766-2617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-235-9657
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/28/2025

Additional Information

Authorized Official

Authorized Official Last Name:
VALE
Authorized Official First Name:
JUNIPER
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
971-235-9657

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com