Basic Information
| Provider Information | |||||||||
| NPI: | 1114044344 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHERN COUNTIES HEALTH CARE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NORTHERN COUNTIES DENTAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 165 SHERMAN DRIVE | ||||||||
| Address2: | |||||||||
| City: | ST. JOHNSBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027489405 | ||||||||
| FaxNumber: | 8027484540 | ||||||||
| Practice Location | |||||||||
| Address1: | 151 NORTH MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | HARDWICK | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024722260 | ||||||||
| FaxNumber: | 8024722263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2007 | ||||||||
| LastUpdateDate: | 01/30/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FLOOD | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR/CEO | ||||||||
| AuthorizedOfficialTelephone: | 8027489405 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTHERN COUNTIES HEALTH CARE, INC. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
ID Information
| ID | Type | State | Issuer | Description | 2332 | 01 | VT | BC GROUP NUMBER | OTHER |