1932627312 NPI number — FUNCTIONAL RD, LLC

Table of content: (NPI 1932627312)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932627312 NPI number — FUNCTIONAL RD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FUNCTIONAL RD, 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:
1932627312
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14439 NW MILITARY HWY STE 108
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHAVANO PARK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78231-1648
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-920-0669
Provider Business Mailing Address Fax Number:
210-920-6645

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 CHIMNEY ROCK LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHAVANO PARK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78231-1648
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-658-5028
Provider Business Practice Location Address Fax Number:
210-920-6645
Provider Enumeration Date:
09/06/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SENIOR
Authorized Official First Name:
AIMEE
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
REGISTERED DIETITIAN
Authorized Official Telephone Number:
210-920-0669

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  DT83404 , 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)