Healthcare Provider Details

I. General information

NPI: 1548505571
Provider Name (Legal Business Name): BERT PRIDDLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2012
Last Update Date: 12/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S WILLOW ST
MANCHESTER NH
03103-3220
US

IV. Provider business mailing address

869 MAIN ST STE 7
WALPOLE MA
02081-2985
US

V. Phone/Fax

Practice location:
  • Phone: 603-622-0899
  • Fax: 603-622-5048
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberH593
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: