1831642396 NPI number — JACLYN A GAMACHE PT, DPT

Table of content: JACLYN A GAMACHE PT, DPT (NPI 1831642396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831642396 NPI number — JACLYN A GAMACHE PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAMACHE
Provider First Name:
JACLYN
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

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:
1831642396
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
794 HITCHCOCK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PITTSFORD
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05763-9544
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-632-4030
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 SCALE AVE
Provider Second Line Business Practice Location Address:
BUILDING 18, SUITE 32
Provider Business Practice Location Address City Name:
RUTLAND
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05701-4452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-855-8068
Provider Business Practice Location Address Fax Number:
802-855-8436
Provider Enumeration Date:
08/01/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  040.0121765 , 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: 13865603 . This is a "CAQH PROVIDER ID" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".




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