Provider Demographics
NPI:1811384555
Name:INTEGRATIVE OSTEOPATHIC MEDICINE & HEALING CENTER, LLC
Entity Type:Organization
Organization Name:INTEGRATIVE OSTEOPATHIC MEDICINE & HEALING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONQUILLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUCHARD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:603-641-2070
Mailing Address - Street 1:16 HIGH ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03101-1610
Mailing Address - Country:US
Mailing Address - Phone:603-641-2070
Mailing Address - Fax:603-641-8084
Practice Address - Street 1:16 HIGH ST
Practice Address - Street 2:SUITE 2
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-1610
Practice Address - Country:US
Practice Address - Phone:603-641-2070
Practice Address - Fax:603-641-8084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH16816204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH1881997716OtherTYPE 1 NPI