MEDICARE: RIVER STREET INTEGRATIVE MEDICINE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	A79910	CA

General Provider Information

NPI Number	:	1417293267
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVER STREET INTEGRATIVE MEDICINE, INC.

Provider Business Mailing Address
First Line	:	700 RIVER ST
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95060-2748
Country	:	US
Telephone Number	:	831-457-2000
Fax Number	:	831-457-2140

Provider Business Practice Location Address
First Line	:	700 RIVER ST
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95060-2748
Country	:	US
Telephone Number	:	831-457-2000
Fax Number	:	831-457-2140

Authorized Official
Title or Position	:	MEDICAL DOCTOR
Name	:	DR. LESTER JAY BRODIE
Credential	:	M.D.
Telephone Number	:	831-457-2000

Provider Enumeration Date	:	12/26/2012
Last Update Date	:	06/13/2013

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