Healthcare Provider Details

I. General information

NPI: 1013089291
Provider Name (Legal Business Name): FUNCTIONAL INDUSTRIAL REHABILITATION MEDICAL ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 07/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6042 N FRESNO ST 101
FRESNO CA
93710-5279
US

IV. Provider business mailing address

6042 N FRESNO ST 101
FRESNO CA
93710-5279
US

V. Phone/Fax

Practice location:
  • Phone: 559-224-6754
  • Fax: 559-490-0105
Mailing address:
  • Phone: 559-224-6754
  • Fax: 559-490-0105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. TIMISHA DENISE GREATHOUSE
Title or Position: OFFICE MANAGER
Credential:
Phone: 559-224-6754