=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477569234
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW CREATION HEALING CENTER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2006
-----------------------------------------------------
Last Update Date | 03/05/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 80 ROUTE 125
-----------------------------------------------------
City | KINGSTON
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03848-3535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-642-6700
-----------------------------------------------------
Fax | 603-642-6701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 80 ROUTE 125
-----------------------------------------------------
City | KINGSTON
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03848-3535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-642-6700
-----------------------------------------------------
Fax | 603-642-6701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO/PHYSICIAN
-----------------------------------------------------
Name | MARY G PEARSON
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 603-642-6700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------