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General NPI Number Information
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NPI Number | 1689059479
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Entity Type | Organization
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Legal Business Name | FUNCTIONAL WELLNESS CENTER LLC
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Dates
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Enumeration Date | 07/22/2015
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Last Update Date | 10/15/2015
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Provider Practice Location Address
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Address Line | 7555 E OSBORN RD STE. 102
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City | SCOTTSDALE
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State | AZ
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Zip | 85251-6434
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Country | US
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Telephone | 517-499-8791
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Fax |
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Provider Business Mailing Address
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Address Line | 7555 E OSBORN RD STE. 102
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City | SCOTTSDALE
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State | AZ
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Zip | 85251-6434
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Country | US
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Telephone | 517-499-8791
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. ANDREW LEE KELLOGG
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Credential | D.C.
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Telephone | 517-499-8791
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 8489
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 8490
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License Number State | AZ
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