Healthcare Provider Details

I. General information

NPI: 1679575385
Provider Name (Legal Business Name): PETER CLARK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/22/2006
Reactivation Date: 03/31/2006

III. Provider practice location address

785 CENTRAL RD
RYE BEACH NH
03871-9005
US

IV. Provider business mailing address

325 MAIN ST PO BOX 882
PLAISTOW NH
03865-3033
US

V. Phone/Fax

Practice location:
  • Phone: 603-964-7740
  • Fax: 603-964-7783
Mailing address:
  • Phone: 603-382-5400
  • Fax: 603-382-4283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number02894
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: