Provider Demographics
NPI:1730521493
Name:SUGAR RIVER FAMILY PRACTICE, P.C.
Entity type:Organization
Organization Name:SUGAR RIVER FAMILY PRACTICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN
Authorized Official - Phone:603-287-8000
Mailing Address - Street 1:31 PLEASANT ST
Mailing Address - Street 2:STE 206
Mailing Address - City:CLAREMONT
Mailing Address - State:NH
Mailing Address - Zip Code:03743-3603
Mailing Address - Country:US
Mailing Address - Phone:603-287-8000
Mailing Address - Fax:603-287-8006
Practice Address - Street 1:31 PLEASANT ST
Practice Address - Street 2:SUITE 206
Practice Address - City:CLAREMONT
Practice Address - State:NH
Practice Address - Zip Code:03743-3603
Practice Address - Country:US
Practice Address - Phone:603-287-8000
Practice Address - Fax:603-287-8006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-23
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH037311-23363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty