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General NPI Number Information
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NPI Number | 1457290710
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Entity Type | Organization
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Legal Business Name | FUNCTIONAL WELLNESS LLC
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Dates
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Enumeration Date | 03/25/2026
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Last Update Date | 03/25/2026
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Provider Practice Location Address
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Address Line | 310 MARLBORO ST STE 267
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City | KEENE
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State | NH
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Zip | 03431-4118
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Country | US
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Telephone | 518-496-0219
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Fax |
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Provider Business Mailing Address
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Address Line | 310 MARLBORO ST STE 267
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City | KEENE
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State | NH
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Zip | 03431-4118
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Country | US
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Telephone | 603-606-0487
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | MICHAEL PETER GRAY
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Credential | LMT
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Telephone | 603-606-0487
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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