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General NPI Number Information
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NPI Number | 1952141475
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Entity Type | Organization
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Legal Business Name | FUNCTIONALCARE 360
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Dates
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Enumeration Date | 05/31/2024
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Last Update Date | 05/31/2024
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Provider Practice Location Address
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Address Line | 9828 AINSLIE DOWNS ST
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City | CHARLOTTE
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State | NC
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Zip | 28273-4976
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Country | US
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Telephone | 331-442-5062
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Fax | 681-201-0332
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Provider Business Mailing Address
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Address Line | 9828 AINSLIE DOWNS ST
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City | CHARLOTTE
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State | NC
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Zip | 28273-4976
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Country | US
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Telephone | 331-442-5062
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Fax | 681-201-0332
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | JARRED FISHER
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Credential | PA-C
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Telephone | 331-442-5062
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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