Provider Demographics
NPI:1639783095
Name:NORTHERN COUNTIES HEALTH CARE, INC.
Entity Type:Organization
Organization Name:NORTHERN COUNTIES HEALTH CARE, INC.
Other - Org Name:NORTHERN EXPRESS CARE ST. JOHNSBURY
Other - Org Type:Other Name
Authorized Official - Title/Position:HUMAN RESOURCES ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:MEGHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-748-9405
Mailing Address - Street 1:165 SHERMAN DR
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-9811
Mailing Address - Country:US
Mailing Address - Phone:802-748-9405
Mailing Address - Fax:
Practice Address - Street 1:1 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-2661
Practice Address - Country:US
Practice Address - Phone:802-748-9405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHERN COUNTIES HEALTH CARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-03
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1009361Medicaid