Healthcare Provider Details

I. General information

NPI: 1346587664
Provider Name (Legal Business Name): ROSWELL CHILDS DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2013
Last Update Date: 10/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 CENTRE ST
CONCORD NH
03301-4214
US

IV. Provider business mailing address

91A N STATE ST
CONCORD NH
03301-4334
US

V. Phone/Fax

Practice location:
  • Phone: 603-224-3511
  • Fax: 603-224-3556
Mailing address:
  • Phone: 781-961-3370
  • Fax: 781-767-7531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3694
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: