Healthcare Provider Details

I. General information

NPI: 1780969345
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: 10/14/2011
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GENERAL WING RD
RUTLAND VT
05701-4681
US

IV. Provider business mailing address

71 ALLEN ST SUITE 101
RUTLAND VT
05701-4570
US

V. Phone/Fax

Practice location:
  • Phone: 802-773-9131
  • Fax: 802-773-1551
Mailing address:
  • Phone: 800-468-9118
  • Fax: 802-772-7973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

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