1215367891 NPI number — INDIAN STREAM HEALTH CENTER, INC

Table of content: (NPI 1215367891)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215367891 NPI number — INDIAN STREAM HEALTH CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIAN STREAM HEALTH CENTER, INC
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:
1215367891
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
141 CORLISS LN
Provider Second Line Business Mailing Address:
CANAAN SITE
Provider Business Mailing Address City Name:
COLEBROOK
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03576-3206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-237-8336
Provider Business Mailing Address Fax Number:
603-237-4467

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
253 GALE ST
Provider Second Line Business Practice Location Address:
CANAAN SITE
Provider Business Practice Location Address City Name:
CANAAN
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-237-8336
Provider Business Practice Location Address Fax Number:
603-237-4467
Provider Enumeration Date:
11/19/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
603-388-2426

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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