Healthcare Provider Details

I. General information

NPI: 1588982912
Provider Name (Legal Business Name): NORTHEAST NATURAL MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2010
Last Update Date: 05/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 MAIN ST SUITE 15
NEWTOWN CT
06470-2129
US

IV. Provider business mailing address

107 EDGELAKE DR
SANDY HOOK CT
06482-1140
US

V. Phone/Fax

Practice location:
  • Phone: 800-723-2962
  • Fax: 800-957-5421
Mailing address:
  • Phone: 203-947-2412
  • Fax: 800-957-5421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number004130
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number425
License Number StateCT

VIII. Authorized Official

Name: DR. SHAWN MORGAN CARNEY
Title or Position: OWNER PRESIDENT MANAGER
Credential: N.D.
Phone: 800-723-2962