Healthcare Provider Details

I. General information

NPI: 1003423724
Provider Name (Legal Business Name): GRANITE STATE GERIATRICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2020
Last Update Date: 09/27/2020
Certification Date: 09/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 MAIN ST STE 303
LACONIA NH
03246-3415
US

IV. Provider business mailing address

32 HARVEST RUN
GILFORD NH
03249-6567
US

V. Phone/Fax

Practice location:
  • Phone: 603-409-0735
  • Fax: 877-919-0640
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. RAYMOND EDWIN SUAREZ
Title or Position: MEMBER
Credential:
Phone: 603-409-0735