Healthcare Provider Details

I. General information

NPI: 1205071404
Provider Name (Legal Business Name): TINA MARIE DEMERS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2008
Last Update Date: 12/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 HARRIS ROAD
NASUA NH
03060
US

IV. Provider business mailing address

79 GROVE AVE
MANCHESTER NH
03109-5044
US

V. Phone/Fax

Practice location:
  • Phone: 603-888-1573
  • Fax:
Mailing address:
  • Phone: 603-669-8561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number0795
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: