Provider Demographics
NPI:1518013622
Name:MARK H. WENTWORTH HOME
Entity Type:Organization
Organization Name:MARK H. WENTWORTH HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:RODIER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:603-436-0169
Mailing Address - Street 1:346 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-4536
Mailing Address - Country:US
Mailing Address - Phone:603-436-0169
Mailing Address - Fax:
Practice Address - Street 1:346 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-4536
Practice Address - Country:US
Practice Address - Phone:603-436-0169
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH00147313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30003658Medicaid