1558465856 NPI number — LORETTO-KERVICK HOMES

Table of content: (NPI 1558465856)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558465856 NPI number — LORETTO-KERVICK HOMES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LORETTO-KERVICK HOMES
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:
1558465856
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
351 NORTH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05401-2921
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-658-6111
Provider Business Mailing Address Fax Number:
802-860-0451

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
131 CONVENT AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUTLAND
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-775-5133
Provider Business Practice Location Address Fax Number:
802-775-0105
Provider Enumeration Date:
09/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PAYEA
Authorized Official First Name:
DENISE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
802-658-6111

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X , with the licence number:  0298 , 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: W47W182 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 047W181 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com