Healthcare Provider Details

I. General information

NPI: 1861004053
Provider Name (Legal Business Name): BETTY C KETCHUM FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2020
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

987 E MAIN ST
CENTER CONWAY NH
03813-4215
US

IV. Provider business mailing address

987 E MAIN ST
CENTER CONWAY NH
03813-4215
US

V. Phone/Fax

Practice location:
  • Phone: 603-356-4980
  • Fax: 603-356-4918
Mailing address:
  • Phone: 603-356-4980
  • Fax: 603-356-4918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SUSAN M RUKA
Title or Position: ADMINISTRATOR
Credential:
Phone: 603-356-4980