Healthcare Provider Details

I. General information

NPI: 1083679203
Provider Name (Legal Business Name): LAURA C DECOSTER ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 KOSCIUSZKO ST
MANCHESTER NH
03101-1608
US

IV. Provider business mailing address

770 DIX ST
MANCHESTER NH
03103-4516
US

V. Phone/Fax

Practice location:
  • Phone: 603-668-1106
  • Fax:
Mailing address:
  • Phone: 603-624-9644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number09
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: