Provider Demographics
NPI:1588982912
Name:NORTHEAST NATURAL MEDICINE, LLC
Entity type:Organization
Organization Name:NORTHEAST NATURAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:MORGAN
Authorized Official - Last Name:CARNEY
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:800-723-2962
Mailing Address - Street 1:107 EDGELAKE DR
Mailing Address - Street 2:
Mailing Address - City:SANDY HOOK
Mailing Address - State:CT
Mailing Address - Zip Code:06482-1140
Mailing Address - Country:US
Mailing Address - Phone:203-947-2412
Mailing Address - Fax:800-957-5421
Practice Address - Street 1:33 MAIN ST
Practice Address - Street 2:SUITE 15
Practice Address - City:NEWTOWN
Practice Address - State:CT
Practice Address - Zip Code:06470-2129
Practice Address - Country:US
Practice Address - Phone:800-723-2962
Practice Address - Fax:800-957-5421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-10
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004130225700000X
CT425175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty