1013562636 NPI number — FIVE-TOWN HEALTH ALLIANCE, INC

Table of content: (NPI 1013562636)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013562636 NPI number — FIVE-TOWN HEALTH ALLIANCE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIVE-TOWN HEALTH ALLIANCE, INC
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:
RED CLOVER FAMILY DENTISTRY
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:
1013562636
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
61 PINE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRISTOL
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05443-1043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-453-3911
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
61 PINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRISTOL
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05443-1043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-453-3911
Provider Business Practice Location Address Fax Number:
802-453-2358
Provider Enumeration Date:
08/09/2019

Additional Information

Authorized Official

Authorized Official Last Name:
HALNON
Authorized Official First Name:
MARTHA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
802-453-5116

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com