Provider Demographics
NPI:1194466284
Name:GRANITE STATE TLC PC
Entity type:Organization
Organization Name:GRANITE STATE TLC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CENTER ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-337-3178
Mailing Address - Street 1:10 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:NH
Mailing Address - Zip Code:03051-5154
Mailing Address - Country:US
Mailing Address - Phone:978-337-3178
Mailing Address - Fax:
Practice Address - Street 1:3 FLAGSTONE DR
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:NH
Practice Address - Zip Code:03051
Practice Address - Country:US
Practice Address - Phone:978-337-3178
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care