1225514136 NPI number — MISSION FUNCTIONAL MEDICINE, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225514136 NPI number — MISSION FUNCTIONAL MEDICINE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSION FUNCTIONAL MEDICINE, 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:
1225514136
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
103 CHANCELLORSVILLE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STEPHENS CITY
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22655-4515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-247-8476
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
230 COSTELLO DR STE 210
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINCHESTER
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22602-4310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-247-8476
Provider Business Practice Location Address Fax Number:
540-869-3524
Provider Enumeration Date:
07/13/2018

Additional Information

Authorized Official

Authorized Official Last Name:
LAWSON
Authorized Official First Name:
SHAWN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
540-247-8476

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  0102202773 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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