Healthcare Provider Details

I. General information

NPI: 1619694478
Provider Name (Legal Business Name): WINOOSKI INTEGRATIVE MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 MAIN ST STE B
WINOOSKI VT
05404-1380
US

IV. Provider business mailing address

321 MAIN ST STE B
WINOOSKI VT
05404-1380
US

V. Phone/Fax

Practice location:
  • Phone: 802-636-4133
  • Fax:
Mailing address:
  • Phone: 802-636-4133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SAM RUSSO
Title or Position: PRINCIPAL
Credential: ND,LAC, RMSK
Phone: 802-636-4133