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General NPI Number Information
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NPI Number | 1720961865
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Entity Type | Organization
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Legal Business Name | WILD PRAIRIE PRIMARY CARE PLLC
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Dates
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Enumeration Date | 07/28/2025
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Last Update Date | 10/18/2025
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Provider Practice Location Address
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Address Line | 240 MECHANIC ST STE 201
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City | LEBANON
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State | NH
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Zip | 03766-2617
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Country | US
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Telephone | 971-235-9657
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Fax |
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Provider Business Mailing Address
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Address Line | 240 MECHANIC ST STE 201
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City | LEBANON
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State | NH
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Zip | 03766-2617
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Country | US
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Telephone | 603-727-9175
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Fax | 603-988-0711
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Authorized Official
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Title or Position | OWNER
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Name | JUNIPER VALE
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Credential | MD
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Telephone | 603-727-9175
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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