Healthcare Provider Details

I. General information

NPI: 1679391635
Provider Name (Legal Business Name): FUNCTIONALLY FIT CHIROPRACTIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2024
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3802 MURRELL RD
ROCKLEDGE FL
32955-4741
US

IV. Provider business mailing address

7777 N WICKHAM RD UNIT 12-514
MELBOURNE FL
32940-7976
US

V. Phone/Fax

Practice location:
  • Phone: 321-877-2090
  • Fax: 321-349-0217
Mailing address:
  • Phone: 321-877-2090
  • Fax: 321-349-0217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GERALD BOWMAN
Title or Position: OWNER/MANAGER
Credential: DC
Phone: 321-877-2090