Shady Grove Farm and Wellness Center

Primary specialty

Early Intervention Provider AgencyTaxonomy code 252Y00000X

License

011853-1 Issued in NY

Legal business name

SHADY GROVE FARM AND WELLNESS CENTER

Practice address

844 State Route 22B
Peru, NY 12972-5421

Phone

(518) 569-3440

NPI assigned

Feb 28, 2013

Last updated

Feb 28, 2013By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Karen M Bouchard-Braun, PT

Title

President

Phone

(518) 569-3440

Specialties & licenses 1

Addresses

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Karen M Bouchard, PT, NCS

  • Specialist
  • Plattsburgh, NY
  • NPI 1437370327
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1362009600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1362009600000",
    "number": "1326388331",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "844 STATE ROUTE 22B",
            "city": "PERU",
            "state": "NY",
            "postal_code": "129725421",
            "telephone_number": "518-569-3440"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "844 STATE ROUTE 22B",
            "city": "PERU",
            "state": "NY",
            "postal_code": "129725421",
            "telephone_number": "518-569-3440"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHADY GROVE FARM AND WELLNESS CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-02-28",
        "last_updated": "2013-02-28",
        "status": "A",
        "authorized_official_last_name": "BOUCHARD-BRAUN",
        "authorized_official_first_name": "KAREN",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "518-569-3440",
        "authorized_official_credential": "PT"
    },
    "taxonomies": [
        {
            "code": "252Y00000X",
            "taxonomy_group": "",
            "desc": "Early Intervention Provider Agency",
            "state": "NY",
            "license": "011853-1",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Peru Family Medicine, PLLC (Peru Family Healthcare)
• Peru Pharmacy Inc. (Peru Healthmart Pharmacy)
• Alison Rosenbaum, LMHC
• Michelle Marie Rushby, NURSE PRACTITIONER
• Brittany Patinka Saunders, RN
• Lawrence Kenneth Shanley, PHARM. D
• Lawrence Ketrick Shanley, RPH
• David W Smith, M.D.
• Sara Spear, LMHC
• Vicki Sue Tedford, SNT

• Early Intervention Provider Agency in Peru, NY
• Providers in Peru, NY by specialty
• Early Intervention Provider Agency in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 28, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.