Healthcare Provider Details

I. General information

NPI: 1295360618
Provider Name (Legal Business Name): MH MANOR SOUTH OPERATING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2020
Last Update Date: 03/05/2020
Certification Date: 03/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 HARBOR VIEW RD
SOUTH BURLINGTON VT
05403-7850
US

IV. Provider business mailing address

20 HARBOR VIEW RD
SOUTH BURLINGTON VT
05403-7850
US

V. Phone/Fax

Practice location:
  • Phone: 802-863-7897
  • Fax: 802-863-9728
Mailing address:
  • Phone: 802-863-7897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. HENRY J VAUGHN
Title or Position: REIMBURSEMENT ANALYST
Credential:
Phone: 240-595-6025