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General NPI Number Information
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NPI Number | 1568615441
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Entity Type | Organization
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Legal Business Name | SANCTUARY INTEGRATIVE MEDICINE PC
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Dates
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Enumeration Date | 10/23/2008
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Last Update Date | 06/18/2010
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Provider Practice Location Address
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Address Line | 90 MAHONEY AVE
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City | RUTLAND
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State | VT
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Zip | 05701-4836
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Country | US
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Telephone | 802-775-7848
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Fax | 802-774-5145
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Provider Business Mailing Address
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Address Line | 90 MAHONEY AVE
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City | RUTLAND
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State | VT
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Zip | 05701-4836
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Country | US
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Telephone | 802-775-7848
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Fax | 802-774-5145
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Authorized Official
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Title or Position | PROVIDER
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Name | MARK E LOGAN
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Credential | MD
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Telephone | 802-775-7848
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2083P0901X
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Taxonomy Name | Public Health & General Preventive Medicine Physician
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License Number | 0420006819
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License Number State | VT
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