Healthcare Provider Details

I. General information

NPI: 1881742369
Provider Name (Legal Business Name): INTEGRATIVE MEDICINE AND BIOFEEDBACK CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 09/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 E GATE DR STE B
MOUNT LAUREL NJ
08054-1238
US

IV. Provider business mailing address

813 E GATE DR STE B
MOUNT LAUREL NJ
08054-1238
US

V. Phone/Fax

Practice location:
  • Phone: 856-222-9965
  • Fax: 856-222-9916
Mailing address:
  • Phone: 856-222-9965
  • Fax: 856-222-9916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB05189200
License Number StateNJ
# 6
Primary TaxonomyN
Taxonomy Code246ZE0500X
TaxonomyEEG Specialist/Technologist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name: C. SAMUEL VERGHESE
Title or Position: CLINICAL DIRECTOR
Credential: MD(AM), PHD
Phone: 856-222-9965