Healthcare Provider Details

I. General information

NPI: 1124681846
Provider Name (Legal Business Name): DARTMOUTH-HITCHCOCK CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 04/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 MECHANIC ST STE B3-1
LEBANON NH
03766-1537
US

IV. Provider business mailing address

PO BOX 810
HANOVER NH
03755-0810
US

V. Phone/Fax

Practice location:
  • Phone: 603-653-1860
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DANIEL P JANTZEN
Title or Position: CFO
Credential: CPA
Phone: 603-650-5634