Provider Demographics
NPI:1629285697
Name:MISTY HEATHER MORN COMMUNITY CARE HOME
Entity Type:Organization
Organization Name:MISTY HEATHER MORN COMMUNITY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FRANCETTA
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:TICE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:802-265-3300
Mailing Address - Street 1:PO BOX 176
Mailing Address - Street 2:
Mailing Address - City:HYDEVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05750-0176
Mailing Address - Country:US
Mailing Address - Phone:802-265-3300
Mailing Address - Fax:802-265-3300
Practice Address - Street 1:174 BLISSVILLE RD
Practice Address - Street 2:
Practice Address - City:HYDEVILLE
Practice Address - State:VT
Practice Address - Zip Code:05750-0176
Practice Address - Country:US
Practice Address - Phone:802-265-3300
Practice Address - Fax:802-265-3300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0174311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT047W125Medicaid
VT047W187Medicaid