Healthcare Provider Details

I. General information

NPI: 1013840081
Provider Name (Legal Business Name): BRADLEY DEBOER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

69 ALLEN ST STE 7&10
RUTLAND VT
05701-4564
US

IV. Provider business mailing address

69 ALLEN ST STE 7&10
RUTLAND VT
05701-4564
US

V. Phone/Fax

Practice location:
  • Phone: 802-774-5050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number016.0134441
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: