Healthcare Provider Details

I. General information

NPI: 1629285697
Provider Name (Legal Business Name): MISTY HEATHER MORN COMMUNITY CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

174 BLISSVILLE RD
HYDEVILLE VT
05750-0176
US

IV. Provider business mailing address

PO BOX 176
HYDEVILLE VT
05750-0176
US

V. Phone/Fax

Practice location:
  • Phone: 802-265-3300
  • Fax: 802-265-3300
Mailing address:
  • Phone: 802-265-3300
  • Fax: 802-265-3300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number0174
License Number StateVT

VIII. Authorized Official

Name: MRS. FRANCETTA IRENE TICE
Title or Position: OWNER
Credential: R.N.
Phone: 802-265-3300