1780637074 NPI number — MS. BETH ALISON FUNKHOUSER MED, ATC, CSCS

Table of content: MS. BETH ALISON FUNKHOUSER MED, ATC, CSCS (NPI 1780637074)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780637074 NPI number — MS. BETH ALISON FUNKHOUSER MED, ATC, CSCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FUNKHOUSER
Provider First Name:
BETH
Provider Middle Name:
ALISON
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MED, ATC, CSCS
Provider Gender Code:
F

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:
1780637074
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 947
Provider Second Line Business Mailing Address:
EMORY & HENRY COLLEGE- KING ATHLETIC CENTER
Provider Business Mailing Address City Name:
EMORY
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-698-7530
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12228 ITTA BENA DR
Provider Second Line Business Practice Location Address:
EMORY & HENRY COLLEGE- KING ATHLETIC CENTER
Provider Business Practice Location Address City Name:
EMORY
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-944-6590
Provider Business Practice Location Address Fax Number:
276-944-6738
Provider Enumeration Date:
05/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  0126000437 , 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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