MEDICARE: OMNIMED FUNCTIONAL WELLNESS PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM2500X	Medical Specialty Clinic/Center

General Provider Information

NPI Number	:	1619827086
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMNIMED FUNCTIONAL WELLNESS PLLC

Provider Business Mailing Address
First Line	:	17102 HIGHWAY 46 W STE 14
Second Line	:
City	:	SPRING BRANCH
State	:	TX
Zip	:	78070-7120
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	17102 HIGHWAY 46 W STE 14
Second Line	:
City	:	SPRING BRANCH
State	:	TX
Zip	:	78070-7120
Country	:	US
Telephone Number	:	830-214-2211
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JORDAN MASSO
Credential	:	DC
Telephone Number	:	830-214-2211

Provider Enumeration Date	:	02/03/2026
Last Update Date	:	02/03/2026

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