Healthcare Provider Details

I. General information

NPI: 1114142825
Provider Name (Legal Business Name): ROXANNE HANSON LADABOUCHE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 CANADA ST
SWANTON VT
05488-1041
US

IV. Provider business mailing address

34 CANADA ST
SWANTON VT
05488-1041
US

V. Phone/Fax

Practice location:
  • Phone: 802-868-3903
  • Fax: 802-868-4339
Mailing address:
  • Phone: 802-868-3903
  • Fax: 802-868-4339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number0038
License Number StateVT

VIII. Authorized Official

Name: MRS. ROXANNE L LADABOUCHE
Title or Position: MANAGER
Credential: LPN
Phone: 802-868-3903