Provider Demographics
NPI:1467887158
Name:PENINSULA NATUROPATHIC MEDICINE
Entity Type:Organization
Organization Name:PENINSULA NATUROPATHIC MEDICINE
Other - Org Name:PENINSULA INTEGRATIVE MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:ND, LAC
Authorized Official - Phone:650-564-7060
Mailing Address - Street 1:2107 AITKEN AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-2201
Mailing Address - Country:US
Mailing Address - Phone:560-564-7060
Mailing Address - Fax:
Practice Address - Street 1:2635 MIDDLEFIELD RD
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94306-2516
Practice Address - Country:US
Practice Address - Phone:560-564-7060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC14320171100000X
CAND419175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty