Provider Demographics
NPI:1063715886
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:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:L
Authorized Official - Last Name:WHITMER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:802-468-5641
Mailing Address - Street 1:4 COMMONS ST
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4651
Mailing Address - Country:US
Mailing Address - Phone:802-773-1321
Mailing Address - Fax:
Practice Address - Street 1:4 COMMONS ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4651
Practice Address - Country:US
Practice Address - Phone:802-773-1321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-16
Last Update Date:2011-08-10
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
VT0471838Medicaid
VT0471838Medicaid