Healthcare Provider Details

I. General information

NPI: 1689705139
Provider Name (Legal Business Name): GREEN MOUNTAIN REHABILITATION & SPORTS MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 11/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 MAIN ST
BURLINGTON VT
05401-8419
US

IV. Provider business mailing address

90 MAIN ST
BURLINGTON VT
05401-8419
US

V. Phone/Fax

Practice location:
  • Phone: 802-861-6700
  • Fax: 802-861-2143
Mailing address:
  • Phone: 802-861-6700
  • Fax: 802-861-2143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number040-0003401
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number040-0003248
License Number StateVT

VIII. Authorized Official

Name: ERIC ELSINGER
Title or Position: MEMBER
Credential: MSPT
Phone: 802-861-6700