Healthcare Provider Details

I. General information

NPI: 1376326017
Provider Name (Legal Business Name): FUNCTIONAL ATHLETICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2023
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 CAMINO DEL RIO S STE 203
SAN DIEGO CA
92108-3506
US

IV. Provider business mailing address

409 CAMINO DEL RIO S STE 203
SAN DIEGO CA
92108-3506
US

V. Phone/Fax

Practice location:
  • Phone: 619-294-3259
  • Fax:
Mailing address:
  • Phone: 619-294-3259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number State

VIII. Authorized Official

Name: TIM GEORGE
Title or Position: OWNER/CLINIC DIRECTOR
Credential:
Phone: 619-294-3259