Provider Demographics
NPI:1639381668
Name:CONNECTICUT VALLEY RECOVERY SERVICES, INC.
Entity Type:Organization
Organization Name:CONNECTICUT VALLEY RECOVERY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLIFTON
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:LORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-356-6496
Mailing Address - Street 1:141 ETTA FRASIER DR
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:VT
Mailing Address - Zip Code:05089-1315
Mailing Address - Country:US
Mailing Address - Phone:802-674-9400
Mailing Address - Fax:802-674-9410
Practice Address - Street 1:141 ETTA FRASIER DR
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:VT
Practice Address - Zip Code:05089-1315
Practice Address - Country:US
Practice Address - Phone:802-674-9400
Practice Address - Fax:802-674-9410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0006638Medicaid
VT0004475Medicare PIN
VT0006638Medicaid