Provider Demographics
NPI:1194817684
Name:LRG HEALTHCARE
Entity Type:Organization
Organization Name:LRG HEALTHCARE
Other - Org Name:LACONIA CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-524-5151
Mailing Address - Street 1:PO BOX 10005
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-9432
Mailing Address - Country:US
Mailing Address - Phone:603-524-5151
Mailing Address - Fax:
Practice Address - Street 1:724 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LACONIA
Practice Address - State:NH
Practice Address - Zip Code:03246-2742
Practice Address - Country:US
Practice Address - Phone:603-524-5151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHRE8109OtherMEDICARE GROUP NUMBER