1417958356 NPI number — THE TRUSTEES OF THE GILL ODD FELLOWS HOME OF VERMONT

Table of content: (NPI 1417958356)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417958356 NPI number — THE TRUSTEES OF THE GILL ODD FELLOWS HOME OF VERMONT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE TRUSTEES OF THE GILL ODD FELLOWS HOME OF VERMONT
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:
GILL ODD FELLOWS HOME
Provider Other Organization Name Type Code:
3
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:
1417958356
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8 GILL TERRACE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUDLOW
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-228-4571
Provider Business Mailing Address Fax Number:
802-228-2229

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8 GILL TER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUDLOW
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05149-1004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-228-4571
Provider Business Practice Location Address Fax Number:
802-228-2229
Provider Enumeration Date:
08/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SOUTHWORTH
Authorized Official First Name:
THERESA
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
NURSING HOME ADMINISTRATOR
Authorized Official Telephone Number:
802-228-4571

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 385H00000X , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 047-5052 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 047R008 . This is a "RESPITE PROVIDER#" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".




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