=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275126757
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FUNCTIONAL MEDICINE CENTER OF THE CAROLINAS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2021
-----------------------------------------------------
Last Update Date | 02/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 GILEAD RD # 1555
-----------------------------------------------------
City | HUNTERSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28078-6899
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-274-2005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14928 OLD VERMILLION DR
-----------------------------------------------------
City | HUNTERSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28078-5337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-770-6847
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DANIEL RASHID
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 704-770-6847
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 133NN1002X
-----------------------------------------------------
Taxonomy Name | Nutrition Education Nutritionist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------