Healthcare Provider Details

I. General information

NPI: 1841484854
Provider Name (Legal Business Name): LIFE CIRCLE FAMILY PRACTICE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2007
Last Update Date: 09/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 BELMONT AVE
BRATTLEBORO VT
05301-6614
US

IV. Provider business mailing address

63 BELMONT AVE
BRATTLEBORO VT
05301-6614
US

V. Phone/Fax

Practice location:
  • Phone: 802-254-8300
  • Fax:
Mailing address:
  • Phone: 802-254-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number042-0011317
License Number StateVT

VIII. Authorized Official

Name: DR. KATHLEEN BURGESS
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 802-254-8300