Provider Demographics
NPI:1922130236
Name:STATE STREET ENTERPRISE, LLC
Entity Type:Organization
Organization Name:STATE STREET ENTERPRISE, LLC
Other - Org Name:DAVIS HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:PATCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-674-5300
Mailing Address - Street 1:45 STATE ST
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:VT
Mailing Address - Zip Code:05089-1213
Mailing Address - Country:US
Mailing Address - Phone:802-674-5300
Mailing Address - Fax:802-674-5388
Practice Address - Street 1:45 STATE ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:VT
Practice Address - Zip Code:05089-1213
Practice Address - Country:US
Practice Address - Phone:802-674-5300
Practice Address - Fax:802-674-5388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0021310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT047W175Medicaid
VT047W179Medicaid