1215217641 NPI number — NORTHEAST KINGDOM HEALTHCARE COLLABORATIVE, LLC

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 1215217641 NPI number — NORTHEAST KINGDOM HEALTHCARE COLLABORATIVE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST KINGDOM HEALTHCARE COLLABORATIVE, LLC
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:
1215217641
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
186 MEDICAL VILLAGE DR, SUITE 1
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
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-487-2589
Provider Business Mailing Address Fax Number:
802-334-3281

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
468 HOSPITAL DRIVE
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:
802-748-7901
Provider Business Practice Location Address Fax Number:
802-427-3047
Provider Enumeration Date:
08/17/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
L
Authorized Official Title or Position:
ENROLLMENT SPECIALIST
Authorized Official Telephone Number:
802-487-2589

Provider Taxonomy Codes

  • Taxonomy code: 207RS0012X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1019637 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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