Healthcare Provider Details

I. General information

NPI: 1295852549
Provider Name (Legal Business Name): NORTHERN COUNTIES HEALTH CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 06/11/2021
Certification Date: 06/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 SHERMAN DR
ST JOHNSBURY VT
05819-9811
US

IV. Provider business mailing address

165 SHERMAN DRIVE
ST JOHNSBURY VT
05819
US

V. Phone/Fax

Practice location:
  • Phone: 802-695-2512
  • Fax: 802-695-1303
Mailing address:
  • Phone: 802-748-9405
  • Fax: 802-748-4540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL COSTA
Title or Position: EXECUTIVE DIRECTOR/CEO
Credential:
Phone: 802-748-9405