Healthcare Provider Details

I. General information

NPI: 1578001996
Provider Name (Legal Business Name): JUSTIN DEVOID
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2017
Last Update Date: 02/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

691 WILLARD RD
QUECHEE VT
05059-0505
US

IV. Provider business mailing address

PO BOX 505 691 WILLARD ROAD
QUECHEE VT
05059-0505
US

V. Phone/Fax

Practice location:
  • Phone: 802-738-4115
  • Fax:
Mailing address:
  • Phone: 802-738-4115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: