Healthcare Provider Details

I. General information

NPI: 1902064496
Provider Name (Legal Business Name): COLD HOLLOW FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2008
Last Update Date: 05/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 WATER TOWER RD SUITE 1
ENOSBURG FALLS VT
05450-6097
US

IV. Provider business mailing address

84 WATER TOWER RD SUITE 1
ENOSBURG FALLS VT
05450-6097
US

V. Phone/Fax

Practice location:
  • Phone: 802-933-6664
  • Fax: 802-933-8333
Mailing address:
  • Phone: 802-933-6664
  • Fax: 802-933-8333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CANDACE M COLLINS
Title or Position: CLINIC ADMINISTRATOR
Credential:
Phone: 802-933-6664