Provider Demographics
NPI:1255521845
Name:SOJOURNS COMMUNITY HEALTH CLINIC
Entity type:Organization
Organization Name:SOJOURNS COMMUNITY HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-722-4023
Mailing Address - Street 1:4923 US ROUTE 5
Mailing Address - Street 2:SOJOURNS COMMUNITY HEALTH CLINIC
Mailing Address - City:WESTMINSTER
Mailing Address - State:VT
Mailing Address - Zip Code:05158-9651
Mailing Address - Country:US
Mailing Address - Phone:802-722-4023
Mailing Address - Fax:802-722-4137
Practice Address - Street 1:4923 US ROUTE 5
Practice Address - Street 2:SOJOURNS COMMUNITY HEALTH CLINIC
Practice Address - City:WESTMINSTER
Practice Address - State:VT
Practice Address - Zip Code:05158-9651
Practice Address - Country:US
Practice Address - Phone:802-722-4023
Practice Address - Fax:802-722-4137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN2821Medicaid