Provider Demographics
NPI:1174656201
Name:NORTHERN COUNTIES HEALTH CARE, INC.
Entity Type:Organization
Organization Name:NORTHERN COUNTIES HEALTH CARE, INC.
Other - Org Name:CALEDONIA HOME HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:DONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-748-9405
Mailing Address - Street 1:161 SHERMAN DRVIE
Mailing Address - Street 2:
Mailing Address - City:ST. JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819
Mailing Address - Country:US
Mailing Address - Phone:802-748-8116
Mailing Address - Fax:802-748-4628
Practice Address - Street 1:161 SHERMAN DRVIE
Practice Address - Street 2:
Practice Address - City:ST. JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819
Practice Address - Country:US
Practice Address - Phone:802-748-8116
Practice Address - Fax:802-748-4628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTT001703OtherCHAMPUS-HOSPICE
VT1005248Medicaid
VT1004923Medicaid
VT1005008Medicaid
VT1005275Medicaid
VT47-W004Medicaid
VT1005248Medicaid
VT1004923Medicaid