Provider Demographics
NPI:1114536877
Name:INTEGRATIVE HEALTH & WELLNESS CLINIC
Entity Type:Organization
Organization Name:INTEGRATIVE HEALTH & WELLNESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARYLOU
Authorized Official - Middle Name:
Authorized Official - Last Name:CASSIDY
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:603-831-1191
Mailing Address - Street 1:48 NORTH RD
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:NH
Mailing Address - Zip Code:03449-5508
Mailing Address - Country:US
Mailing Address - Phone:603-831-1911
Mailing Address - Fax:833-924-0345
Practice Address - Street 1:1283 MAIN ST UNIT 6C
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:NH
Practice Address - Zip Code:03444-8242
Practice Address - Country:US
Practice Address - Phone:603-831-1191
Practice Address - Fax:833-924-0345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-29
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH1114536877Medicaid