1346619509 NPI number — FUNCTIONAL IMPROVEMENT THERAPY LLC

Table of content: MR. CARLTON JEROME WOODBURY BS PHARMACY (NPI 1134403413)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346619509 NPI number — FUNCTIONAL IMPROVEMENT THERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FUNCTIONAL IMPROVEMENT THERAPY LLC
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:
1346619509
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3213 RIDGE TRACE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANSFIELD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76063-5365
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-808-5353
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4200 SW GREEN OAKS BLVD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76017-4162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-478-5800
Provider Business Practice Location Address Fax Number:
817-478-5803
Provider Enumeration Date:
09/17/2015

Additional Information

Authorized Official

Authorized Official Last Name:
DUONG
Authorized Official First Name:
PETER
Authorized Official Middle Name:
TUYEN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
817-473-4348

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  13007 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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