1811241094 NPI number — COMMUNITY HEALTH CENTERS OF THE RUTLAND REGION, INC

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 1811241094 NPI number — COMMUNITY HEALTH CENTERS OF THE RUTLAND REGION, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY HEALTH CENTERS OF THE RUTLAND REGION, 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:
SHOREWELL COMMUNITY HEALTH CENTER
Provider Other Organization Name Type Code:
3
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:
1811241094
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
71 ALLEN ST
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
RUTLAND
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05701-4570
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-468-9118
Provider Business Mailing Address Fax Number:
802-772-7973

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2987 VT ROUTE 22A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHOREHAM
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05770-9728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-897-7000
Provider Business Practice Location Address Fax Number:
802-897-7718
Provider Enumeration Date:
11/09/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GARDNER
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
FINANCE DIRECTOR
Authorized Official Telephone Number:
802-885-2083

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1021223 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0471844 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 03891792 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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