Provider Demographics
NPI:1467681114
Name:COMMUNITY HEALTH CENTERS OF THE RUTLAND REGION INC
Entity type:Organization
Organization Name:COMMUNITY HEALTH CENTERS OF THE RUTLAND REGION INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-855-2083
Mailing Address - Street 1:71 ALLEN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4570
Mailing Address - Country:US
Mailing Address - Phone:800-468-9118
Mailing Address - Fax:802-772-7973
Practice Address - Street 1:215 STRATTON RD
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4621
Practice Address - Country:US
Practice Address - Phone:802-773-3386
Practice Address - Fax:802-773-4578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-02
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03891783Medicaid
VT1017651Medicaid
VT0471836Medicaid
VT0471836Medicaid
VT1017651Medicaid