=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245721620
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FUNCTIONAL HEALTH PLANNING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2018
-----------------------------------------------------
Last Update Date | 07/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 MAIN STREET MVP ATHLETIC CLUB, #237
-----------------------------------------------------
City | LADY LAKE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-571-5155
-----------------------------------------------------
Fax | 352-633-1396
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 MAIN STREET MVP ATHLETIC CLUB, #237
-----------------------------------------------------
City | LADY LAKE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-571-5155
-----------------------------------------------------
Fax | 352-633-1396
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ALEXANDER CHARLES FRANK
-----------------------------------------------------
Credential | DC, DACNB
-----------------------------------------------------
Telephone | 352-571-5155
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NN0400X
-----------------------------------------------------
Taxonomy Name | Neurology Chiropractor
-----------------------------------------------------
License Number | CH10093
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------