Provider Demographics
NPI:1932162674
Name:MVAMC
Entity type:Organization
Organization Name:MVAMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:603-624-4366
Mailing Address - Street 1:718 SMYTH RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03104-7004
Mailing Address - Country:US
Mailing Address - Phone:603-624-4366
Mailing Address - Fax:603-629-3263
Practice Address - Street 1:718 SMYTH RD
Practice Address - Street 2:MVAMC
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-7004
Practice Address - Country:US
Practice Address - Phone:603-624-4366
Practice Address - Fax:603-629-3263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3283749465261QF0400X
NH011837-23-03261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Not Answered261Q00000XAmbulatory Health Care FacilitiesClinic/Center