Healthcare Provider Details

I. General information

NPI: 1114366887
Provider Name (Legal Business Name): GRANITE STATE ADAPTIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2013
Last Update Date: 06/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 MIRROR LAKE DR
MIRROR LAKE NH
03853-5953
US

IV. Provider business mailing address

PO BOX 24
MIRROR LAKE NH
03853-0024
US

V. Phone/Fax

Practice location:
  • Phone: 603-387-1167
  • Fax:
Mailing address:
  • Phone: 603-387-1167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number681
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2924M
License Number StateNH

VIII. Authorized Official

Name: MRS. JENNIFER FRASER HAYNES
Title or Position: PRESIDENT
Credential: PT
Phone: 603-387-1167