Provider Demographics
NPI:1316000284
Name:CARLOS OTIS STRATTON MT CLINIC INC
Entity Type:Organization
Organization Name:CARLOS OTIS STRATTON MT CLINIC INC
Other - Org Name:OTIS CLINIC STRATTON MT CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:HAND
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:802-297-2300
Mailing Address - Street 1:PO BOX 617
Mailing Address - Street 2:
Mailing Address - City:STRATTON MT
Mailing Address - State:VT
Mailing Address - Zip Code:05155
Mailing Address - Country:US
Mailing Address - Phone:802-297-2300
Mailing Address - Fax:802-297-3412
Practice Address - Street 1:78 FOUNDERS HILL ROAD
Practice Address - Street 2:
Practice Address - City:STRATTON MT
Practice Address - State:VT
Practice Address - Zip Code:05155
Practice Address - Country:US
Practice Address - Phone:802-297-2300
Practice Address - Fax:802-297-3412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT3016458OtherVT BCBS NON PAR