Healthcare Provider Details

I. General information

NPI: 1013562636
Provider Name (Legal Business Name): FIVE-TOWN HEALTH ALLIANCE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2019
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 PINE ST
BRISTOL VT
05443-1043
US

IV. Provider business mailing address

61 PINE ST
BRISTOL VT
05443-1043
US

V. Phone/Fax

Practice location:
  • Phone: 802-453-3911
  • Fax: 802-453-2358
Mailing address:
  • Phone: 802-453-3911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: HEIDI MELBOSTAD
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 802-453-5116