Healthcare Provider Details

I. General information

NPI: 1053428151
Provider Name (Legal Business Name): CLIFFORD W KORN LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 09/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 INDIAN ROCK ROAD
WINDHAM NH
03087-1656
US

IV. Provider business mailing address

87 INDIAN ROCK ROAD WINDHAM HEALTH CENTER
WINDHAM NH
03087-1656
US

V. Phone/Fax

Practice location:
  • Phone: 603-894-6402
  • Fax:
Mailing address:
  • Phone: 603-894-6402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number692M
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA38765
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: