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General NPI Number Information
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NPI Number | 1417293267
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Entity Type | Organization
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Legal Business Name | RIVER STREET INTEGRATIVE MEDICINE, INC.
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Dates
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Enumeration Date | 12/26/2012
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Last Update Date | 06/13/2013
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Provider Practice Location Address
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Address Line | 700 RIVER ST
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City | SANTA CRUZ
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State | CA
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Zip | 95060-2748
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Country | US
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Telephone | 831-457-2000
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Fax | 831-457-2140
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Provider Business Mailing Address
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Address Line | 700 RIVER ST
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City | SANTA CRUZ
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State | CA
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Zip | 95060-2748
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Country | US
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Telephone | 831-457-2000
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Fax | 831-457-2140
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Authorized Official
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Title or Position | MEDICAL DOCTOR
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Name | DR. LESTER JAY BRODIE
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Credential | M.D.
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Telephone | 831-457-2000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | A79910
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License Number State | CA
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