Healthcare Provider Details

I. General information

NPI: 1225979123
Provider Name (Legal Business Name): MEC CONCORD OBS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 RIVER RD
MANCHESTER NH
03104-2423
US

IV. Provider business mailing address

250 RIVER RD
MANCHESTER NH
03104-2423
US

V. Phone/Fax

Practice location:
  • Phone: 603-668-2020
  • Fax:
Mailing address:
  • Phone: 603-668-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JACKIE WIEDEMANN
Title or Position: BILLING MANAGER
Credential:
Phone: 816-610-8511