Provider Demographics
NPI:1508571043
Name:MILLDALE FARM CENTER FOR WELLNESS PLC
Entity Type:Organization
Organization Name:MILLDALE FARM CENTER FOR WELLNESS PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-299-1467
Mailing Address - Street 1:1461 BLOOD BROOK RD
Mailing Address - Street 2:
Mailing Address - City:FAIRLEE
Mailing Address - State:VT
Mailing Address - Zip Code:05045-9847
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1461 BLOOD BROOK RD
Practice Address - Street 2:
Practice Address - City:FAIRLEE
Practice Address - State:VT
Practice Address - Zip Code:05045-9847
Practice Address - Country:US
Practice Address - Phone:802-299-1467
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1417420290Medicaid