Provider Demographics
NPI:1215217641
Name:NORTHEAST KINGDOM HEALTHCARE COLLABORATIVE, LLC
Entity Type:Organization
Organization Name:NORTHEAST KINGDOM HEALTHCARE COLLABORATIVE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:BISSONNETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:8023-343-3253
Mailing Address - Street 1:55 SHERMAN DR
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:802-334-7331
Mailing Address - Fax:
Practice Address - Street 1:55 SHERMAN DRIVE
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05401
Practice Address - Country:US
Practice Address - Phone:802-334-4111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-17
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty