Provider Demographics
NPI:1003019837
Name:COOS COUNTY FAMILY HEALTH SERVICES
Entity Type:Organization
Organization Name:COOS COUNTY FAMILY HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-752-3669
Mailing Address - Street 1:133 PLEASANT STREET
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:NH
Mailing Address - Zip Code:03570
Mailing Address - Country:US
Mailing Address - Phone:603-752-2040
Mailing Address - Fax:603-752-1709
Practice Address - Street 1:73 MAIN STREET
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:NH
Practice Address - Zip Code:03570
Practice Address - Country:US
Practice Address - Phone:603-752-2424
Practice Address - Fax:603-752-2436
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COOS COUNTY FAMILY HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-08
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH04258122300000X
NH12751223G0001X
NH012751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30301511Medicaid
NH30301511Medicaid