1174656201 NPI number — NORTHERN COUNTIES HEALTH CARE, INC.

Table of content: (NPI 1174656201)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174656201 NPI number — NORTHERN COUNTIES HEALTH CARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN COUNTIES HEALTH CARE, 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:
1174656201
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:
161 SHERMAN DRVIE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST. JOHNSBURY
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-748-8116
Provider Business Mailing Address Fax Number:
802-748-4628

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
161 SHERMAN DRVIE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST. JOHNSBURY
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-748-8116
Provider Business Practice Location Address Fax Number:
802-748-4628
Provider Enumeration Date:
03/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DONNELLY
Authorized Official First Name:
JACK
Authorized Official Middle Name:
Authorized Official Title or Position:
INTERIM EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
802-748-9405

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , 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: T001703 . This is a "CHAMPUS-HOSPICE" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 1005248 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1004923 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1005008 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1005275 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 47-W004 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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