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General NPI Number Information
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NPI Number | 1396521134
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Entity Type | Organization
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Legal Business Name | FUNCTIONAL HEALTH REVOLUTION
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Dates
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Enumeration Date | 09/07/2023
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Last Update Date | 11/22/2024
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Provider Practice Location Address
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Address Line | 4445 CORPORATION LN STE 264
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City | VIRGINIA BEACH
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State | VA
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Zip | 23462-3671
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Country | US
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Telephone | 703-214-5121
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Fax |
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Provider Business Mailing Address
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Address Line | 3301 RICHMOND HWY # 1127
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City | ALEXANDRIA
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State | VA
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Zip | 22305-3044
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Country | US
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Telephone | 703-214-5121
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | KIM SEIDL
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Credential |
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Telephone | 703-214-5121
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171400000X
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Taxonomy Name | Health & Wellness Coach
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License Number |
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License Number State |
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