Provider Demographics
NPI:1053490896
Name:VINEYARD COMPLEMENTARY MEDICINE, INC
Entity Type:Organization
Organization Name:VINEYARD COMPLEMENTARY MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:508-693-3800
Mailing Address - Street 1:PO BOX 1760
Mailing Address - Street 2:
Mailing Address - City:EDGARTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02539-1760
Mailing Address - Country:US
Mailing Address - Phone:508-693-3800
Mailing Address - Fax:508-693-7473
Practice Address - Street 1:238 EDGARTOWN VINEYARD HAVEN ROAD
Practice Address - Street 2:UNIT 1
Practice Address - City:EDGARTOWN
Practice Address - State:MA
Practice Address - Zip Code:02539-6932
Practice Address - Country:US
Practice Address - Phone:508-693-3800
Practice Address - Fax:508-693-7473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X, 225X00000X, 261QX0100X
MA687261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY61445OtherBCBS OF MA
AA52541OtherHPHC
PT0283Medicare ID - Type Unspecified