Healthcare Provider Details

I. General information

NPI: 1235870205
Provider Name (Legal Business Name): FUNCTIONAL MEDICINE CENTER OF ARIZONA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 04/05/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 S 56TH AVE STE 1B
PHOENIX AZ
85043-4630
US

IV. Provider business mailing address

806 S 56TH AVE STE 1B
PHOENIX AZ
85043-4630
US

V. Phone/Fax

Practice location:
  • Phone: 602-429-0447
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY TIEDEMANN
Title or Position: OWNER/CLINICAL DIRECTOR
Credential:
Phone: 480-747-0499