Provider Demographics
NPI:1760727978
Name:MOOSILAUKE VISIONS, INC.
Entity type:Organization
Organization Name:MOOSILAUKE VISIONS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-359-9044
Mailing Address - Street 1:633 NH ROUTE 10
Mailing Address - Street 2:PO BOX 325
Mailing Address - City:ORFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03777
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23 S MAIN ST STE 2A
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:NH
Practice Address - Zip Code:03755-2075
Practice Address - Country:US
Practice Address - Phone:603-691-3435
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-29
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty