Healthcare Provider Details

I. General information

NPI: 1881727543
Provider Name (Legal Business Name): NORTHEAST KINGDOM HUMAN SERVICES INC CSUB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 SEYMOUR LN
NEWPORT VT
05855-2199
US

IV. Provider business mailing address

PO BOX 724
NEWPORT VT
05855-0724
US

V. Phone/Fax

Practice location:
  • Phone: 802-334-5246
  • Fax: 802-334-1093
Mailing address:
  • Phone: 802-334-6744
  • Fax: 802-334-7340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ERIC GRIMS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 802-334-6744