Provider Demographics
NPI:1023323037
Name:WINTERGREEN RESIDENTIAL CARE, LLC
Entity type:Organization
Organization Name:WINTERGREEN RESIDENTIAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-465-4101
Mailing Address - Street 1:PO BOX 206
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:VT
Mailing Address - Zip Code:05733-0206
Mailing Address - Country:US
Mailing Address - Phone:802-465-4101
Mailing Address - Fax:
Practice Address - Street 1:3 UNION ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:VT
Practice Address - Zip Code:05733-1127
Practice Address - Country:US
Practice Address - Phone:802-465-4101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care