Basic Information
| Provider Information | |||||||||
| NPI: | 1104870922 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH CENTERS OF THE RUTLAND REGION, INC. | ||||||||
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| OtherOrganizationName: | DBA METTOWEE VALLEY FAMILY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 71 ALLEN ST | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | RUTLAND | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057014570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027724414 | ||||||||
| FaxNumber: | 8027727973 | ||||||||
| Practice Location | |||||||||
| Address1: | 278 VT ROUTE 149 | ||||||||
| Address2: | |||||||||
| City: | WEST PAWLET | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057759798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8026450580 | ||||||||
| FaxNumber: | 8026450587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 09/11/2018 | ||||||||
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| AuthorizedOfficialLastName: | GARDNER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | FINANCE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8028552080 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 471816 | 01 | VT | NAT'L GOV SERVICES | OTHER | 03044048 | 05 | NY | MEDICAID | 1010850 | 05 | VT | MEDICAID |