Provider Demographics
NPI:1043207566
Name:ALICE PECK DAY MEMORIAL HOSPITAL-ECU
Entity Type:Organization
Organization Name:ALICE PECK DAY MEMORIAL HOSPITAL-ECU
Other - Org Name:EXTENDED CARE FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:G
Authorized Official - Last Name:DORMAN
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:603-448-3121
Mailing Address - Street 1:125 MASCOMA ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766-2647
Mailing Address - Country:US
Mailing Address - Phone:603-448-3121
Mailing Address - Fax:603-448-7462
Practice Address - Street 1:125 MASCOMA ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-2647
Practice Address - Country:US
Practice Address - Phone:603-448-3121
Practice Address - Fax:603-448-7462
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALICE PECK DAY MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-30
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0016A311ZA0620X, 313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH80305033Medicaid
VT0305033Medicaid
NH80305033Medicaid