Healthcare Provider Details

I. General information

NPI: 1114529237
Provider Name (Legal Business Name): FUNDAMENTAL HEALTH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2020
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 S CREASY LN STE K3
LAFAYETTE IN
47905-7430
US

IV. Provider business mailing address

1221 S CREASY LN STE K3
LAFAYETTE IN
47905-7430
US

V. Phone/Fax

Practice location:
  • Phone: 765-838-2310
  • Fax: 765-838-1035
Mailing address:
  • Phone: 765-838-2310
  • Fax: 765-838-1035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. JULIE CHRISTINE MIRANDA
Title or Position: PRACTICE MANAGER
Credential: LPN
Phone: 765-838-2310