Provider Demographics
NPI:1083133870
Name:NORTH COUNTRY MEDICAL AND WELLNESS, LLC
Entity Type:Organization
Organization Name:NORTH COUNTRY MEDICAL AND WELLNESS, LLC
Other - Org Name:VAILAS MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:VAILAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-731-5589
Mailing Address - Street 1:700 LAKE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-2734
Mailing Address - Country:US
Mailing Address - Phone:603-621-0681
Mailing Address - Fax:
Practice Address - Street 1:152 COLBY ST
Practice Address - Street 2:
Practice Address - City:COLEBROOK
Practice Address - State:NH
Practice Address - Zip Code:03576
Practice Address - Country:US
Practice Address - Phone:603-731-5589
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-13
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care