Provider Demographics
NPI:1114226743
Name:INTEGRATED MEDICINE: CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:INTEGRATED MEDICINE: CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:802-458-0488
Mailing Address - Street 1:PO BOX 705
Mailing Address - Street 2:
Mailing Address - City:EAST MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05740-0705
Mailing Address - Country:US
Mailing Address - Phone:802-458-0488
Mailing Address - Fax:802-458-0489
Practice Address - Street 1:1641 ROUTE 7 S
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-8806
Practice Address - Country:US
Practice Address - Phone:802-458-0488
Practice Address - Fax:802-458-0489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT006-0001191111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1015096Medicaid