1003409319 NPI number — FUNCTIONAL MEDICINE OF NEVADA PLLC

Table of content: (NPI 1003409319)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003409319 NPI number — FUNCTIONAL MEDICINE OF NEVADA PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FUNCTIONAL MEDICINE OF NEVADA PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003409319
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3858 N GARDEN CENTER WAY STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83703-5008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-385-7711
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6490 S MCCARRAN BLVD STE 16
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RENO
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89509-6165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-385-7711
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/17/2021

Additional Information

Authorized Official

Authorized Official Last Name:
WARREN
Authorized Official First Name:
SAM
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
208-385-7711

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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