Healthcare Provider Details

I. General information

NPI: 1215167556
Provider Name (Legal Business Name): RAGGED MOUNTAIN ORTHOPAEDIC & SPORTS PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2009
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 LAWRENCE STREET
ANDOVER NH
03216
US

IV. Provider business mailing address

PO BOX 146
ANDOVER NH
03216-0146
US

V. Phone/Fax

Practice location:
  • Phone: 603-735-5114
  • Fax:
Mailing address:
  • Phone: 603-735-5114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number2130
License Number StateNH

VIII. Authorized Official

Name: DIANE FOWLER
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: MPT
Phone: 603-735-5114