Provider Demographics
NPI:1902132962
Name:PELLAGRINO, ROBERT GLYNN (LICAC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:GLYNN
Last Name:PELLAGRINO
Suffix:
Gender:M
Credentials:LICAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 442
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:VT
Mailing Address - Zip Code:05039-0442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:720 VILLAGE RD.
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:VT
Practice Address - Zip Code:05040
Practice Address - Country:US
Practice Address - Phone:802-439-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-27
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT091-0000039171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist