Healthcare Provider Details

I. General information

NPI: 1649705583
Provider Name (Legal Business Name): ALASKA FUNCTIONAL MEDICINE CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2017
Last Update Date: 04/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9138 ARLON ST SUITE A2
ANCHORAGE AK
99507-3876
US

IV. Provider business mailing address

9138 ARLON ST SUITE A2
ANCHORAGE AK
99507-3876
US

V. Phone/Fax

Practice location:
  • Phone: 907-375-9395
  • Fax: 907-375-9396
Mailing address:
  • Phone: 907-375-9395
  • Fax: 907-375-9396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CHRIS BENNETT
Title or Position: OWNER
Credential: FNP
Phone: 907-375-9395