Healthcare Provider Details

I. General information

NPI: 1598238792
Provider Name (Legal Business Name): VINEYARD COMPLEMENTARY MEDICINE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2019
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238 EDGARTOWN VINEYARD HAVEN ROAD UNIT 1
EDGARTOWN MA
02539-6932
US

IV. Provider business mailing address

PO BOX 1760
EDGARTOWN MA
02539-1760
US

V. Phone/Fax

Practice location:
  • Phone: 508-693-3800
  • Fax: 508-693-7473
Mailing address:
  • Phone: 508-693-3800
  • Fax: 508-693-7473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: SUSAN SANFORD
Title or Position: PRESIDENT
Credential: PT, LIC. AC
Phone: 508-693-3800