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General NPI Number Information
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NPI Number | 1871974337
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Entity Type | Organization
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Legal Business Name | FUNCTIONAL MEDICINE OF CARMEL INC.
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Dates
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Enumeration Date | 06/10/2015
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Last Update Date | 06/10/2015
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Provider Practice Location Address
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Address Line | 755 W CARMEL DR SUITE 212
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City | CARMEL
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State | IN
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Zip | 46032-5877
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Country | US
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Telephone | 765-318-3265
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Fax |
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Provider Business Mailing Address
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Address Line | 755 W CARMEL DR SUITE 212
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City | CARMEL
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State | IN
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Zip | 46032-5877
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Country | US
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Telephone | 765-318-3265
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LYNNOVA REYNOLDS
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Credential | D.O.
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Telephone | 765-318-3265
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207VX0000X
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Taxonomy Name | Obstetrics Physician
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License Number | 02001906A
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License Number State | IN
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