Provider Demographics
NPI:1326388331
Name:SHADY GROVE FARM AND WELLNESS CENTER
Entity Type:Organization
Organization Name:SHADY GROVE FARM AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOUCHARD-BRAUN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:518-569-3440
Mailing Address - Street 1:844 STATE ROUTE 22B
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:NY
Mailing Address - Zip Code:12972-5421
Mailing Address - Country:US
Mailing Address - Phone:518-569-3440
Mailing Address - Fax:
Practice Address - Street 1:844 STATE ROUTE 22B
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:NY
Practice Address - Zip Code:12972-5421
Practice Address - Country:US
Practice Address - Phone:518-569-3440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-28
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011853-1252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency