Provider Demographics
NPI:1255547261
Name:PEMBROKE WELLNESS CENTER
Entity type:Organization
Organization Name:PEMBROKE WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBBORAH
Authorized Official - Middle Name:J
Authorized Official - Last Name:KAITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-485-7788
Mailing Address - Street 1:48 GLASS ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NH
Mailing Address - Zip Code:03275-1506
Mailing Address - Country:US
Mailing Address - Phone:603-485-7788
Mailing Address - Fax:
Practice Address - Street 1:48 GLASS ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NH
Practice Address - Zip Code:03275-1506
Practice Address - Country:US
Practice Address - Phone:603-485-7788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH37162OtherCIGNA
NH30010430Medicaid
NH=========Medicare ID - Type Unspecified