Provider Demographics
NPI:1548687502
Name:VERMONT BACK AND BODY CARE, LLC
Entity type:Organization
Organization Name:VERMONT BACK AND BODY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:LANE
Authorized Official - Last Name:CONNOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:802-225-8958
Mailing Address - Street 1:338 RIVER ST
Mailing Address - Street 2:SUITE #8
Mailing Address - City:MONTPELIER
Mailing Address - State:VT
Mailing Address - Zip Code:05602-8242
Mailing Address - Country:US
Mailing Address - Phone:802-225-8958
Mailing Address - Fax:802-225-8969
Practice Address - Street 1:338 RIVER ST
Practice Address - Street 2:SUITE #8
Practice Address - City:MONTPELIER
Practice Address - State:VT
Practice Address - Zip Code:05602-8242
Practice Address - Country:US
Practice Address - Phone:802-225-8958
Practice Address - Fax:802-225-8969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-27
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT006.0001133111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN3297Medicaid