Provider Demographics
NPI:1902064496
Name:COLD HOLLOW FAMILY PRACTICE
Entity Type:Organization
Organization Name:COLD HOLLOW FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:M
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-933-6664
Mailing Address - Street 1:84 WATER TOWER RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ENOSBURG FALLS
Mailing Address - State:VT
Mailing Address - Zip Code:05450-6097
Mailing Address - Country:US
Mailing Address - Phone:802-933-6664
Mailing Address - Fax:802-933-8333
Practice Address - Street 1:84 WATER TOWER RD
Practice Address - Street 2:SUITE 1
Practice Address - City:ENOSBURG FALLS
Practice Address - State:VT
Practice Address - Zip Code:05450-6097
Practice Address - Country:US
Practice Address - Phone:802-933-6664
Practice Address - Fax:802-933-8333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1014837Medicaid