Healthcare Provider Details

I. General information

NPI: 1427458124
Provider Name (Legal Business Name): NORTHEASTERN REPRODUCTIVE MEDICINE LABORATORIES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2014
Last Update Date: 03/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 WESTVIEW RD SUITE 302
COLCHESTER VT
05446-8025
US

IV. Provider business mailing address

105 WESTVIEW RD SUITE 302
COLCHESTER VT
05446-8025
US

V. Phone/Fax

Practice location:
  • Phone: 802-655-8888
  • Fax: 802-985-2566
Mailing address:
  • Phone: 802-655-8888
  • Fax: 802-985-2566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number47D2079212
License Number StateVT

VIII. Authorized Official

Name: PETER R. CASSON
Title or Position: AUTHORIZED REP/OWNER
Credential: MD
Phone: 802-655-8888