Healthcare Provider Details

I. General information

NPI: 1386581775
Provider Name (Legal Business Name): IDA'S HOUSE OF VERMONT PROFESSIONAL LIMITED LIABILITY COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2026
Last Update Date: 05/02/2026
Certification Date: 05/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 NEW RD
BRANDON VT
05733-8396
US

IV. Provider business mailing address

360 NEW RD
BRANDON VT
05733-8396
US

V. Phone/Fax

Practice location:
  • Phone: 802-247-0381
  • Fax: 888-502-6598
Mailing address:
  • Phone: 802-247-0381
  • Fax: 888-502-6598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: DR. TINEY RAY
Title or Position: OWNER
Credential: PHD, DNP, FNP,PMHNP
Phone: 678-701-4679