1275830739 NPI number — STARRY BROOK NATURAL MEDICINE, LLC

Table of content: (NPI 1275830739)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275830739 NPI number — STARRY BROOK NATURAL MEDICINE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STARRY BROOK NATURAL MEDICINE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275830739
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14 BOW ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EXETER
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03833-2828
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-583-5181
Provider Business Mailing Address Fax Number:
603-583-5194

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
60 SOUTH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEERFIELD
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-583-5181
Provider Business Practice Location Address Fax Number:
844-364-9449
Provider Enumeration Date:
02/18/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GIARD
Authorized Official First Name:
ROBYN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
603-583-5181

Provider Taxonomy Codes

  • Taxonomy code: 175F00000X , with the licence number:  82 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 302F00000X , with the licence number: 82 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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