Healthcare Provider Details

I. General information

NPI: 1669445763
Provider Name (Legal Business Name): WALTER E CHAMBERLAIN JR. OPTICIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 S SPRING ST
CONCORD NH
03301-2425
US

IV. Provider business mailing address

9 S SPRING ST
CONCORD NH
03301-2425
US

V. Phone/Fax

Practice location:
  • Phone: 603-228-1104
  • Fax: 603-228-7061
Mailing address:
  • Phone: 603-228-1104
  • Fax: 603-228-7061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number976
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: