Healthcare Provider Details

I. General information

NPI: 1639873839
Provider Name (Legal Business Name): RIVER'S EDGE INTEGRATIVE MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2023
Last Update Date: 03/30/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4374 RT 100
WARREN VT
05674-0567
US

IV. Provider business mailing address

4372 VERMONT ROUTE 100
WARREN VT
05674-9728
US

V. Phone/Fax

Practice location:
  • Phone: 802-744-7284
  • Fax:
Mailing address:
  • Phone: 603-783-6714
  • Fax: 949-437-3084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CARLENE VASQUEZ-BROWN
Title or Position: OWNER/MEMBER
Credential:
Phone: 802-744-7284