Healthcare Provider Details

I. General information

NPI: 1811656895
Provider Name (Legal Business Name): GRANITE STATE EYE ASSOCIATES P.L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2021
Last Update Date: 03/15/2022
Certification Date: 03/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 ROUTE 111
ATKINSON NH
03811-5120
US

IV. Provider business mailing address

16 PARTRIDGE RD
WINDHAM NH
03087-1256
US

V. Phone/Fax

Practice location:
  • Phone: 603-819-5327
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateNULL

VIII. Authorized Official

Name: PATRICK MALLIN
Title or Position: MANAGER
Credential: OD
Phone: 603-602-7321