Healthcare Provider Details

I. General information

NPI: 1114086808
Provider Name (Legal Business Name): MAD RIVER INTEGRATIVE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5360 MAIN ST STE 2
WAITSFIELD VT
05673-6003
US

IV. Provider business mailing address

5360 MAIN ST STE 2
WAITSFIELD VT
05673-6003
US

V. Phone/Fax

Practice location:
  • Phone: 802-496-2202
  • Fax: 802-496-2223
Mailing address:
  • Phone: 802-496-2202
  • Fax: 802-496-2223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number042-0007289
License Number StateVT

VIII. Authorized Official

Name: DR. TIMOTHY J WARGO
Title or Position: PRESIDENT
Credential: M.D
Phone: 802-496-2202