Provider Demographics
NPI:1295197549
Name:HUMPHREYS, JOHN (LMT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:HUMPHREYS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 W RIDGE TER
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-9168
Mailing Address - Country:US
Mailing Address - Phone:518-321-5545
Mailing Address - Fax:
Practice Address - Street 1:8 CONANT SQ
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:VT
Practice Address - Zip Code:05733-1018
Practice Address - Country:US
Practice Address - Phone:518-321-5545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-25
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026030174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist