Provider Demographics
NPI:1053732792
Name:BOARDMAN, VICTOR
Entity type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:
Last Name:BOARDMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 HEGEMAN AVE
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-3156
Mailing Address - Country:US
Mailing Address - Phone:802-660-4046
Mailing Address - Fax:
Practice Address - Street 1:404 SUGAR TREE LN
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6780
Practice Address - Country:US
Practice Address - Phone:802-660-4046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-24
Last Update Date:2013-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0750016788376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide