=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497018147
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATIVE FAMILY HEALTH & WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2012
-----------------------------------------------------
Last Update Date | 06/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19 HALLS RD SUITE 208
-----------------------------------------------------
City | OLD LYME
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06371-1457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-598-0404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2329 GLASGO RD
-----------------------------------------------------
City | GRISWOLD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06351-9114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-598-0404
-----------------------------------------------------
Fax | 860-434-3262
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DR. LAURA A MUNRO
-----------------------------------------------------
Credential | ND
-----------------------------------------------------
Telephone | 860-598-0404
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175F00000X
-----------------------------------------------------
Taxonomy Name | Naturopath
-----------------------------------------------------
License Number | 000481
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------