Basic Information
| Provider Information | |||||||||
| NPI: | 1013069376 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STRAFFORD HEALTH ALLIANCE | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WOMEN'S LIFE IMAGING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 ROUTE 108 | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | SOMERSWORTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038781119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037427492 | ||||||||
| FaxNumber: | 6037426762 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 ROUTE 108 | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | SOMERSWORTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038781119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037427492 | ||||||||
| FaxNumber: | 6037426762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 01/08/2009 | ||||||||
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| AuthorizedOfficialLastName: | BEAUDIN | ||||||||
| AuthorizedOfficialFirstName: | BETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6037426673 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2471M2300X | Y | 193400000X SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Mammography |
ID Information
| ID | Type | State | Issuer | Description | 155010 | 01 | NH | FDA CERTIFICATE # | OTHER |