Healthcare Provider Details

I. General information

NPI: 1699918284
Provider Name (Legal Business Name): HEALTHCARE CENTER OF FUNCTIONAL MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2009
Last Update Date: 04/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N LYONS ST
BUTLER MO
64730-2131
US

IV. Provider business mailing address

101 N LYONS ST
BUTLER MO
64730-2131
US

V. Phone/Fax

Practice location:
  • Phone: 660-679-4423
  • Fax:
Mailing address:
  • Phone: 660-679-4423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0900X
TaxonomyInternist Chiropractor
License Number2007037820
License Number StateMO

VIII. Authorized Official

Name: DR. TRAVIS MICHAEL KERSHNER
Title or Position: CHIROPRACTOR
Credential: D.C.
Phone: 660-424-3994