Healthcare Provider Details

I. General information

NPI: 1285313643
Provider Name (Legal Business Name): MVTC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2023
Last Update Date: 07/13/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 RIVER RD
PLAINFIELD NH
03781-5044
US

IV. Provider business mailing address

703 RIVER RD
PLAINFIELD NH
03781-5044
US

V. Phone/Fax

Practice location:
  • Phone: 603-989-3500
  • Fax:
Mailing address:
  • Phone: 603-989-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: ADRIAN EVERETT LOGAN
Title or Position: CHIEF OF OPERATIONS AND ENROLLMENT
Credential: MA, GC
Phone: 603-989-3500