Provider Demographics
NPI:1871840843
Name:FIVE-TOWN HEALTH ALLIANCE, INC
Entity Type:Organization
Organization Name:FIVE-TOWN HEALTH ALLIANCE, INC
Other - Org Name:MOUNTAIN HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:A
Authorized Official - Last Name:HALNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-453-5116
Mailing Address - Street 1:61 PINE ST BLDG 4
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VT
Mailing Address - Zip Code:05443-1043
Mailing Address - Country:US
Mailing Address - Phone:802-453-5028
Mailing Address - Fax:802-453-6105
Practice Address - Street 1:61 PINE ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VT
Practice Address - Zip Code:05443-1043
Practice Address - Country:US
Practice Address - Phone:802-453-3911
Practice Address - Fax:802-453-6105
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIVE-TOWN HEALTH ALLIANCE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-09
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 261QD0000X
VT261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT471846OtherMEDICARE PART A FQHC
VT0471846Medicaid
VT1021079Medicaid