Provider Demographics
NPI:1497359103
Name:INTERVENTIONAL SPINE OF VERMONT, PLLC
Entity Type:Organization
Organization Name:INTERVENTIONAL SPINE OF VERMONT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ESTHER
Authorized Official - Middle Name:
Authorized Official - Last Name:CABALLERO-MANRIQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-404-2004
Mailing Address - Street 1:PO BOX 1182
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-1182
Mailing Address - Country:US
Mailing Address - Phone:802-404-2004
Mailing Address - Fax:888-506-2885
Practice Address - Street 1:277 BLAIR PARK RD STE 110
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-7885
Practice Address - Country:US
Practice Address - Phone:802-404-2004
Practice Address - Fax:888-506-2885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-23
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty