Healthcare Provider Details

I. General information

NPI: 1841184983
Provider Name (Legal Business Name): MEDPARK WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2025
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 DERRY RD
HUDSON NH
03051-3303
US

IV. Provider business mailing address

225 DERRY RD
HUDSON NH
03051-3303
US

V. Phone/Fax

Practice location:
  • Phone: 603-595-8989
  • Fax:
Mailing address:
  • Phone: 603-595-8989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: CONNIE MCKAY
Title or Position: OWNER
Credential: OWNER
Phone: 603-595-8989