1033241344 NPI number — NORTHEAST KINGDOM HUMAN SERVICES INC MH ADULT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033241344 NPI number — NORTHEAST KINGDOM HUMAN SERVICES INC MH ADULT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST KINGDOM HUMAN SERVICES INC MH ADULT
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:
1033241344
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 724
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWPORT
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05855-0724
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-334-6744
Provider Business Mailing Address Fax Number:
802-334-7340

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
154 DUCHESS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWPORT
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05855-0724
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-334-6744
Provider Business Practice Location Address Fax Number:
802-334-7340
Provider Enumeration Date:
03/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GRIMS
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
802-334-6744

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0006073 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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