Provider Demographics
NPI:1215151410
Name:STATE OF VERMONT
Entity type:Organization
Organization Name:STATE OF VERMONT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:DALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-863-7284
Mailing Address - Street 1:PO BOX 70, SUITE 202
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05402-0070
Mailing Address - Country:US
Mailing Address - Phone:802-863-7284
Mailing Address - Fax:802-863-7632
Practice Address - Street 1:VERMONT PUBLIC HEALTH LABORATORY
Practice Address - Street 2:359 SOUTH PARK DRIVE
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446
Practice Address - Country:US
Practice Address - Phone:802-863-7284
Practice Address - Fax:802-863-7632
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF VERMONT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-12
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0008013Medicaid
VT0008013Medicaid