Provider Demographics
NPI:1568615441
Name:SANCTUARY INTEGRATIVE MEDICINE PC
Entity Type:Organization
Organization Name:SANCTUARY INTEGRATIVE MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-775-7848
Mailing Address - Street 1:90 MAHONEY AVE
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4836
Mailing Address - Country:US
Mailing Address - Phone:802-775-7848
Mailing Address - Fax:802-774-5145
Practice Address - Street 1:90 MAHONEY AVE
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4836
Practice Address - Country:US
Practice Address - Phone:802-775-7848
Practice Address - Fax:802-774-5145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-23
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT04200068192083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Single Specialty