Healthcare Provider Details

I. General information

NPI: 1225000383
Provider Name (Legal Business Name): PINE KNOLL NURSING HOME, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 RED VILLAGE RD
LYNDONVILLE VT
05851-9068
US

IV. Provider business mailing address

601 RED VILLAGE RD
LYNDONVILLE VT
05851-9068
US

V. Phone/Fax

Practice location:
  • Phone: 802-626-3361
  • Fax: 802-626-4056
Mailing address:
  • Phone: 802-626-3361
  • Fax: 802-626-4056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateVT

VIII. Authorized Official

Name: MR. TRAVIS B BERGERON
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 802-626-3361