Provider Demographics
NPI:1174553283
Name:POULIN PERFORMANCE, INC.
Entity type:Organization
Organization Name:POULIN PERFORMANCE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:AUDETTE
Authorized Official - Last Name:CRITCHLOW
Authorized Official - Suffix:
Authorized Official - Credentials:CAPPM
Authorized Official - Phone:802-656-0949
Mailing Address - Street 1:PO BOX 486
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-0486
Mailing Address - Country:US
Mailing Address - Phone:802-658-0949
Mailing Address - Fax:802-658-1436
Practice Address - Street 1:21 GREGORY DR
Practice Address - Street 2:SUITE 120
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6080
Practice Address - Country:US
Practice Address - Phone:802-658-0949
Practice Address - Fax:802-658-1436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040-0002746225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT0632746OtherCIGNA
VT1009260Medicaid
VT59089OtherBCBS
UT0632746OtherCIGNA