Provider Demographics
NPI:1376738096
Name:AMMONOOSUC COMMUNITY HEALTH SERVICES, INC
Entity Type:Organization
Organization Name:AMMONOOSUC COMMUNITY HEALTH SERVICES, INC
Other - Org Name:
Other - Org Type:
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:
Practice Address - Street 1:40 RAILROAD ST
Practice Address - Street 2:
Practice Address - City:WOODSVILLE
Practice Address - State:NH
Practice Address - Zip Code:03785-1118
Practice Address - Country:US
Practice Address - Phone:603-747-3990
Practice Address - Fax:603-444-3441
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMMONOOSUC COMMUNITY HEALTH SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-06
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH207Q00000X, 208000000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH80301805Medicaid
NHRE2692Medicare UPIN
NH80301805Medicaid