Healthcare Provider Details

I. General information

NPI: 1770508632
Provider Name (Legal Business Name): BERT WILLIAM MATHIESON ND,RD,LD,CDE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 RIVERWAY PL
BEDFORD NH
03110-6764
US

IV. Provider business mailing address

304 RIVERWAY PL
BEDFORD NH
03110-6764
US

V. Phone/Fax

Practice location:
  • Phone: 603-623-6800
  • Fax:
Mailing address:
  • Phone: 603-623-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number811007
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number49
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: