Healthcare Provider Details

I. General information

NPI: 1063974152
Provider Name (Legal Business Name): FEARLESS FUNCTIONAL FITNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 RIVERWALK DR STE 312
SAN MARCOS TX
78666-6936
US

IV. Provider business mailing address

324 RIVERWALK DR STE 312
SAN MARCOS TX
78666-6936
US

V. Phone/Fax

Practice location:
  • Phone: 512-268-9130
  • Fax: 833-437-4389
Mailing address:
  • Phone: 512-268-9130
  • Fax: 833-437-4389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. NICOLE ELIZABETH LAIRD
Title or Position: OWNER, PHYSICAL THERAPIST
Credential: PT, DPT
Phone: 512-730-9600