Healthcare Provider Details

I. General information

NPI: 1104870922
Provider Name (Legal Business Name): COMMUNITY HEALTH CENTERS OF THE RUTLAND REGION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 09/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

278 VT ROUTE 149
WEST PAWLET VT
05775-9798
US

IV. Provider business mailing address

71 ALLEN ST SUITE 403
RUTLAND VT
05701-4570
US

V. Phone/Fax

Practice location:
  • Phone: 802-645-0580
  • Fax: 802-645-0587
Mailing address:
  • Phone: 802-772-4414
  • Fax: 802-772-7973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL L GARDNER
Title or Position: FINANCE DIRECTOR
Credential:
Phone: 802-855-2080