Healthcare Provider Details

I. General information

NPI: 1376917591
Provider Name (Legal Business Name): FUNCTION & HEALTH PROFESSIONALS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2015
Last Update Date: 11/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

685 ARLINGTON PL
MACON GA
31201-1772
US

IV. Provider business mailing address

PO BOX 20731
MACON GA
31205-0731
US

V. Phone/Fax

Practice location:
  • Phone: 478-292-2060
  • Fax:
Mailing address:
  • Phone: 478-292-2060
  • Fax: 877-991-6389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number58891
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number58891
License Number StateGA

VIII. Authorized Official

Name: TIQUELLA SHANTEL KING-WHITBY
Title or Position: CEO
Credential: MD, DABMA
Phone: 404-449-0545