Provider Demographics
NPI:1730101312
Name:NORTHERN COUNTIES HLTH CARE INC
Entity Type:Organization
Organization Name:NORTHERN COUNTIES HLTH CARE INC
Other - Org Name:ISLAND POND HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:DONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-748-9405
Mailing Address - Street 1:PO BOX 425
Mailing Address - Street 2:
Mailing Address - City:ISLAND POND
Mailing Address - State:VT
Mailing Address - Zip Code:05846-0425
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:82 MAPLE STREET
Practice Address - Street 2:
Practice Address - City:ISLAND POND
Practice Address - State:VT
Practice Address - Zip Code:05846-0425
Practice Address - Country:US
Practice Address - Phone:802-723-4300
Practice Address - Fax:802-723-4544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0007175Medicaid
4703270OtherOTHER ID NUMBER-COMMERCIAL NUMBER
VT0007175Medicaid