Healthcare Provider Details

I. General information

NPI: 1336269505
Provider Name (Legal Business Name): UPPER VALLEY SUPPORT GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 FLYNN ST
LEBANON NH
03766-1311
US

IV. Provider business mailing address

12 FLYNN ST
LEBANON NH
03766-1311
US

V. Phone/Fax

Practice location:
  • Phone: 603-448-6311
  • Fax:
Mailing address:
  • Phone: 603-448-6311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number30531857
License Number StateNH

VIII. Authorized Official

Name: MR. PHILIP NORMAN ELLER
Title or Position: EXECUTIVE DIRECTOR
Credential: M.A.
Phone: 603-448-6311