Healthcare Provider Details

I. General information

NPI: 1225400237
Provider Name (Legal Business Name): COMMUNITY HEALTH CENTERS OF THE RUTLAND REGION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2015
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 ALLEN POND SUITE 403
RUTLAND VT
05701-4570
US

IV. Provider business mailing address

71 ALLEN ST SUITE 101
RUTLAND VT
05701-4570
US

V. Phone/Fax

Practice location:
  • Phone: 802-772-7992
  • Fax: 802-772-7973
Mailing address:
  • Phone: 800-468-9118
  • Fax: 802-772-7973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL GARDNER
Title or Position: CEO
Credential:
Phone: 802-855-2083