Healthcare Provider Details

I. General information

NPI: 1760727978
Provider Name (Legal Business Name): MOOSILAUKE VISIONS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2012
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 S MAIN ST STE 2A
HANOVER NH
03755-2075
US

IV. Provider business mailing address

633 NH ROUTE 10 PO BOX 325
ORFORD NH
03777
US

V. Phone/Fax

Practice location:
  • Phone: 603-691-3435
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. JAY WOLTER
Title or Position: CEO
Credential:
Phone: 603-359-9044