Healthcare Provider Details

I. General information

NPI: 1710233259
Provider Name (Legal Business Name): LONG TRAIL PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2012
Last Update Date: 08/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 HUNTINGTON RD
RICHMOND VT
05477-9708
US

IV. Provider business mailing address

789 PINE ST
BURLINGTON VT
05401-4933
US

V. Phone/Fax

Practice location:
  • Phone: 802-434-8495
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1040088590
License Number StateVT

VIII. Authorized Official

Name: JOANNE MILANO
Title or Position: PRESIDENT
Credential:
Phone: 802-865-2222