Healthcare Provider Details

I. General information

NPI: 1285769174
Provider Name (Legal Business Name): OUR LADY OF PROVIDENCE VT. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 W SPRING ST
WINOOSKI VT
05404-1319
US

IV. Provider business mailing address

47 W SPRING ST
WINOOSKI VT
05404-1319
US

V. Phone/Fax

Practice location:
  • Phone: 802-655-2395
  • Fax:
Mailing address:
  • Phone: 802-655-2395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number0198
License Number StateVT

VIII. Authorized Official

Name: CARMEN PROULX
Title or Position: SISTER
Credential:
Phone: 802-655-2395