Provider Demographics
NPI:1932201407
Name:GREEN MOUNTAIN NUTRITION ASSOCIATES
Entity Type:Organization
Organization Name:GREEN MOUNTAIN NUTRITION ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:WATERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-476-7607
Mailing Address - Street 1:1555 CENTER RD
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:VT
Mailing Address - Zip Code:05602-8547
Mailing Address - Country:US
Mailing Address - Phone:802-476-7607
Mailing Address - Fax:802-229-5076
Practice Address - Street 1:20 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BARRE
Practice Address - State:VT
Practice Address - Zip Code:05641-4826
Practice Address - Country:US
Practice Address - Phone:802-476-7607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT074-0000052133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1007363Medicaid
GRMT0133Medicare ID - Type Unspecified