Provider Demographics
NPI:1407332893
Name:ASSOCIATION OF AFRICANS LIVING IN VERMONT
Entity Type:Organization
Organization Name:ASSOCIATION OF AFRICANS LIVING IN VERMONT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:YACOUBA
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:BOGRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-985-3106
Mailing Address - Street 1:20 ALLEN ST FL 3
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-4344
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 ALLEN ST FL 3
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4344
Practice Address - Country:US
Practice Address - Phone:802-985-3106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT000000Medicaid