Provider Demographics
NPI:1215367891
Name:INDIAN STREAM HEALTH CENTER, INC
Entity Type:Organization
Organization Name:INDIAN STREAM HEALTH CENTER, INC
Other - Org Name:CANAAN SITE
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-388-2426
Mailing Address - Street 1:141 CORLISS LN
Mailing Address - Street 2:CANAAN SITE
Mailing Address - City:COLEBROOK
Mailing Address - State:NH
Mailing Address - Zip Code:03576-3206
Mailing Address - Country:US
Mailing Address - Phone:603-237-8336
Mailing Address - Fax:603-237-4467
Practice Address - Street 1:253 GALE ST
Practice Address - Street 2:CANAAN SITE
Practice Address - City:CANAAN
Practice Address - State:VT
Practice Address - Zip Code:05903
Practice Address - Country:US
Practice Address - Phone:603-237-8336
Practice Address - Fax:603-237-4467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-19
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH=========OtherTAX ID