1124313986 NPI number — INTEGRATED MEDICINE NATUROPATHIC PRIMARY CARE

Table of content: (NPI 1124313986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124313986 NPI number — INTEGRATED MEDICINE NATUROPATHIC PRIMARY CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRATED MEDICINE NATUROPATHIC PRIMARY CARE
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:
1124313986
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 705
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST MIDDLEBURY
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05740-0705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-458-0488
Provider Business Mailing Address Fax Number:
802-458-0489

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1641 ROUTE 7 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLEBURY
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05753-8806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-458-0488
Provider Business Practice Location Address Fax Number:
802-458-0489
Provider Enumeration Date:
06/09/2011

Additional Information

Authorized Official

Authorized Official Last Name:
CANNON
Authorized Official First Name:
EMILY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
802-458-0488

Provider Taxonomy Codes

  • Taxonomy code: 175F00000X , with the licence number:  099-0000230 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1015227 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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