Healthcare Provider Details

I. General information

NPI: 1205930336
Provider Name (Legal Business Name): CARLOS G OTIS HEALTH CARE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 06/02/2020
Certification Date: 06/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 GRAFTON RD
TOWNSHEND VT
05353
US

IV. Provider business mailing address

PO BOX 216
TOWNSHEND VT
05353-0216
US

V. Phone/Fax

Practice location:
  • Phone: 802-365-4117
  • Fax: 802-365-7759
Mailing address:
  • Phone: 802-365-4117
  • Fax: 802-365-7759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number038.0003276
License Number StateVT

VIII. Authorized Official

Name: STEPHEN ALAN BROWN
Title or Position: CFO
Credential:
Phone: 802-365-3601