1174553283 NPI number — POULIN PERFORMANCE, INC.

Table of content: (NPI 1174553283)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174553283 NPI number — POULIN PERFORMANCE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POULIN PERFORMANCE, 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:
Provider Other Organization Name Type Code:
6
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:
1174553283
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 486
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLISTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05495-0486
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-658-0949
Provider Business Mailing Address Fax Number:
802-658-1436

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21 GREGORY DR
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
SOUTH BURLINGTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05403-6080
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-658-0949
Provider Business Practice Location Address Fax Number:
802-658-1436
Provider Enumeration Date:
07/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CRITCHLOW
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
AUDETTE
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
802-656-0949

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  040-0002746 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0632746 . This is a "CIGNA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 1009260 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 59089 . This is a "BCBS" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".




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