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General NPI Number Information
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NPI Number | 1194430371
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Entity Type | Organization
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Legal Business Name | CENTER FOR FUNCTIONAL MEDICINE AND ULTIMATE WELLNESS
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Dates
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Enumeration Date | 01/23/2023
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Last Update Date | 01/23/2023
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Provider Practice Location Address
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Address Line | 615 COMMERCE ST
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City | FORT WORTH
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State | TX
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Zip | 76102-5450
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Country | US
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Telephone | 817-764-1148
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Fax |
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Provider Business Mailing Address
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Address Line | 1607 ARROWHEAD DR
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City | PANTEGO
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State | TX
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Zip | 76013-3012
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Country | US
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Telephone | 936-240-0530
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Fax | 682-238-3509
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. JOHN BYRON MCCLAIN SR.
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Credential | MD
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Telephone | 936-240-0530
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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