Healthcare Provider Details

I. General information

NPI: 1174553283
Provider Name (Legal Business Name): POULIN PERFORMANCE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 10/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 GREGORY DR SUITE 120
SOUTH BURLINGTON VT
05403-6080
US

IV. Provider business mailing address

PO BOX 486
WILLISTON VT
05495-0486
US

V. Phone/Fax

Practice location:
  • Phone: 802-658-0949
  • Fax: 802-658-1436
Mailing address:
  • Phone: 802-658-0949
  • Fax: 802-658-1436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number040-0002746
License Number StateVT

VIII. Authorized Official

Name: MS. CYNTHIA AUDETTE CRITCHLOW
Title or Position: PRACTICE ADMINISTRATOR
Credential: CAPPM
Phone: 802-656-0949