Healthcare Provider Details

I. General information

NPI: 1811241094
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: 11/09/2012
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2987 VT ROUTE 22A
SHOREHAM VT
05770-9728
US

IV. Provider business mailing address

71 ALLEN ST SUITE 101
RUTLAND VT
05701-4570
US

V. Phone/Fax

Practice location:
  • Phone: 802-897-7000
  • Fax: 802-897-7718
Mailing address:
  • Phone: 800-468-9118
  • Fax: 802-772-7973

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: MICHAEL GARDNER
Title or Position: FINANCE DIRECTOR
Credential:
Phone: 802-885-2083