| Full Name | |
|---|---|
| Speciality | Custodial Care Facility |
| Location | 23 S Main St, Hanover, New Hampshire |
| Authorized Official Name and Position | Jay Wolter (PRESIDENT) |
| Authorized Official Contact | 6033539102 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 325 Orford NH 03777-0325 Ph: (802) 379-5821 | 23 S Main St Hanover NH 03755-2075 Ph: (603) 353-9102 |
| NPI Number | 1336614478 |
|---|---|
| Provider Enumeration Date | 10/04/2018 |
| Last Update Date | 11/21/2023 |
| Certification Date | 11/21/2023 |
| Medicare PECOS PAC ID | 2264765478 |
|---|---|
| Medicare Enrollment ID | O20190624000462 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1336614478 | NPI | - | NPPES |
| Provider Name | Meredith L Fogg |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1265124564 PECOS PAC ID: 0547629578 Enrollment ID: I20230707003131 |
| Provider Name | Brittany S Little |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1972165983 PECOS PAC ID: 1052640547 Enrollment ID: I20240522001485 |
| Provider Name | Anna Buell |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1427896497 PECOS PAC ID: 1355889668 Enrollment ID: I20240819001109 |
| Provider Name | Susan H Dalen |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1598588444 PECOS PAC ID: 3375078132 Enrollment ID: I20241203001898 |
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