=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497291991
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRITY NATURAL MEDICINE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2017
-----------------------------------------------------
Last Update Date | 01/09/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1057 POQUONNOCK RD
-----------------------------------------------------
City | GROTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06340-6630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-980-1221
-----------------------------------------------------
Fax | 860-415-3166
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24 S BARTLETT RD
-----------------------------------------------------
City | QUAKER HILL
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06375-1102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-980-1221
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NATUROPATHIC PHYSICIAN
-----------------------------------------------------
Name | ALYSSA ANNELLO
-----------------------------------------------------
Credential | N.D.
-----------------------------------------------------
Telephone | 860-980-1221
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175F00000X
-----------------------------------------------------
Taxonomy Name | Naturopath
-----------------------------------------------------
License Number | 582
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------