Healthcare Provider Details

I. General information

NPI: 1811384555
Provider Name (Legal Business Name): INTEGRATIVE OSTEOPATHIC MEDICINE & HEALING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2015
Last Update Date: 04/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 HIGH ST SUITE 2
MANCHESTER NH
03101-1610
US

IV. Provider business mailing address

16 HIGH ST SUITE 2
MANCHESTER NH
03101-1610
US

V. Phone/Fax

Practice location:
  • Phone: 603-641-2070
  • Fax: 603-641-8084
Mailing address:
  • Phone: 603-641-2070
  • Fax: 603-641-8084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number16816
License Number StateNH

VIII. Authorized Official

Name: DR. JONQUILLE BOUCHARD
Title or Position: OWNER
Credential: D.O.
Phone: 603-641-2070