Provider Demographics
NPI:1225400237
Name:COMMUNITY HEALTH CENTERS OF THE RUTLAND REGION, INC.
Entity Type:Organization
Organization Name:COMMUNITY HEALTH CENTERS OF THE RUTLAND REGION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-855-2083
Mailing Address - Street 1:71 ALLEN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4570
Mailing Address - Country:US
Mailing Address - Phone:800-468-9118
Mailing Address - Fax:802-772-7973
Practice Address - Street 1:71 ALLEN POND
Practice Address - Street 2:SUITE 403
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4570
Practice Address - Country:US
Practice Address - Phone:802-772-7992
Practice Address - Fax:802-772-7973
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY HEALTH CENTERS OF THE RUTLAND REGION, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-29
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1025859Medicaid
VT1025859Medicaid