Provider Demographics
NPI:1326195058
Name:FULL CIRCLE CENTER FOR INTEGRATIVE MEDICINE
Entity Type:Organization
Organization Name:FULL CIRCLE CENTER FOR INTEGRATIVE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CORINNE
Authorized Official - Middle Name:VIVIAN
Authorized Official - Last Name:BASCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-840-4701
Mailing Address - Street 1:4641 VALLEY EAST BLVD # 2
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-4630
Mailing Address - Country:US
Mailing Address - Phone:707-840-4701
Mailing Address - Fax:855-420-6321
Practice Address - Street 1:4641 VALLEY EAST BLVD # 2
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-4630
Practice Address - Country:US
Practice Address - Phone:707-840-4701
Practice Address - Fax:855-420-6321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2016-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51185207Q00000X, 207Q00000X
363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0094550Medicaid
CAZZZ23190ZMedicare ID - Type UnspecifiedGROUP IDENTIFICATION