Healthcare Provider Details

I. General information

NPI: 1255547261
Provider Name (Legal Business Name): PEMBROKE WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 GLASS ST
PEMBROKE NH
03275-1506
US

IV. Provider business mailing address

48 GLASS ST
PEMBROKE NH
03275-1506
US

V. Phone/Fax

Practice location:
  • Phone: 603-485-7788
  • Fax:
Mailing address:
  • Phone: 603-485-7788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. DEBBORAH J KAITZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 603-485-7788