1386710861 NPI number — CLARA MARTIN CENTER

Table of content: (NPI 1386710861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386710861 NPI number — CLARA MARTIN CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLARA MARTIN CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386710861
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX G
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RANDOLPH
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-728-4466
Provider Business Mailing Address Fax Number:
802-728-4197

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RANDOLPH
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05060-1330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-728-4466
Provider Business Practice Location Address Fax Number:
802-728-4197
Provider Enumeration Date:
11/28/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GIDNEY
Authorized Official First Name:
MELANIE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIR. QUALITY ASSURANCE
Authorized Official Telephone Number:
802-728-4466

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0855X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP0905X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1003145 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: T000381 . This is a "TRICARE" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: VT6178 . This is a "BLUE CROSS" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 63909C . This is a "MVP" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 93909A . This is a "MVP" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 93909 . This is a "MVP" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 1007256 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1009814 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1027774 . This is a "CIGNA" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 00800321 . This is a "BLUE CROSS" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 1009815 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 63909A . This is a "MVP" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 00006178 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1006421 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50Y083800VT01 . This is a "ANTHEM" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 63909 . This is a "MVP" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 93909C . This is a "MVP" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".