Healthcare Provider Details

I. General information

NPI: 1336764026
Provider Name (Legal Business Name): CENTER FOR FUNCTIONAL MEDICINE & WELLBEING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2020
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 LAFAYETTE RD
PORTSMOUTH NH
03801-6078
US

IV. Provider business mailing address

3201 LAFAYETTE RD
PORTSMOUTH NH
03801-6078
US

V. Phone/Fax

Practice location:
  • Phone: 603-380-9159
  • Fax:
Mailing address:
  • Phone: 603-380-9159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JEFFREY DONATELLO
Title or Position: OWNER
Credential: DO
Phone: 207-451-7438