Provider Demographics
NPI:1164631552
Name:AMMONOOSUC COMMUNITY HEALTH SERVICES, INC
Entity Type:Organization
Organization Name:AMMONOOSUC COMMUNITY HEALTH SERVICES, INC
Other - Org Name:AMMONOOSUC COMMUNITY HEALTH SERVICES, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:SHANSHALA II
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-444-2464
Mailing Address - Street 1:25 MOUNT EUSTIS RD
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:NH
Mailing Address - Zip Code:03561-3712
Mailing Address - Country:US
Mailing Address - Phone:603-444-2464
Mailing Address - Fax:603-444-3441
Practice Address - Street 1:14 KING SQ
Practice Address - Street 2:
Practice Address - City:WHITEFIELD
Practice Address - State:NH
Practice Address - Zip Code:03598-3302
Practice Address - Country:US
Practice Address - Phone:603-837-2333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMMONOOSUC COMMUNITY HEALTH SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-22
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH80301207Medicaid
RE2692Medicare UPIN
301807Medicare ID - Type Unspecified
NH80301207Medicaid
NHRE2692Medicare PIN