Healthcare Provider Details

I. General information

NPI: 1386673952
Provider Name (Legal Business Name): INDIAN STREAM HEALTH CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 01/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 CORLISS LANE
COLEBROOK NH
03576
US

IV. Provider business mailing address

141 CORLISS LANE
COLEBROOK NH
03576
US

V. Phone/Fax

Practice location:
  • Phone: 603-237-8336
  • Fax: 603-237-4467
Mailing address:
  • Phone: 603-237-8336
  • Fax: 603-237-4467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNH

VIII. Authorized Official

Name: MR. JONATHAN W. BROWN
Title or Position: CEO
Credential:
Phone: 603-388-2426