Basic Information
| Provider Information | |||||||||
| NPI: | 1902944846 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLARA MARTIN CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | VT | ||||||||
| PostalCode: | 050601330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027284466 | ||||||||
| FaxNumber: | 8027284197 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | VT | ||||||||
| PostalCode: | 050601330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027284466 | ||||||||
| FaxNumber: | 8027284197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CHAMBERS | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8027284466 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LADC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 251S00000X | X | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1006646 | 05 | VT | MEDICAID | 6030006 | 05 | VT | MEDICAID |