Basic Information
| Provider Information | |||||||||
| NPI: | 1326478702 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GIFFORD HEALTH CARE, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | GIFFORD PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 44 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | VT | ||||||||
| PostalCode: | 050601381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027287000 | ||||||||
| FaxNumber: | 8027284245 | ||||||||
| Practice Location | |||||||||
| Address1: | 44 S MAIN ST STE 2 | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | VT | ||||||||
| PostalCode: | 050601381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027287000 | ||||||||
| FaxNumber: | 8027284245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2013 | ||||||||
| LastUpdateDate: | 08/03/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BENNETT | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8027282211 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GIFFORD HEALTH CARE, INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | VT | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.