=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205888781
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UPPER VALLEY REHABILITATION, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2006
-----------------------------------------------------
Last Update Date | 01/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2588 E WOODSTOCK RD
-----------------------------------------------------
City | WOODSTOCK
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05091-3661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-457-4213
-----------------------------------------------------
Fax | 802-457-9870
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 28
-----------------------------------------------------
City | WOODSTOCK
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05091-0028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-457-4213
-----------------------------------------------------
Fax | 802-457-9870
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOSHYUA ROYLANCE
-----------------------------------------------------
Credential | PT, MBA
-----------------------------------------------------
Telephone | 802-457-4213
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 040-0003101
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------