Healthcare Provider Details

I. General information

NPI: 1063715886
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: 12/16/2010
Last Update Date: 08/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 COMMONS ST
RUTLAND VT
05701-4651
US

IV. Provider business mailing address

4 COMMONS ST
RUTLAND VT
05701-4651
US

V. Phone/Fax

Practice location:
  • Phone: 802-773-1321
  • Fax:
Mailing address:
  • Phone: 802-773-1321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. GRANT L WHITMER JR.
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 802-468-5641