Provider Demographics
NPI:1003409319
Name:FUNCTIONAL MEDICINE OF NEVADA PLLC
Entity Type:Organization
Organization Name:FUNCTIONAL MEDICINE OF NEVADA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-385-7711
Mailing Address - Street 1:3858 N GARDEN CENTER WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-5008
Mailing Address - Country:US
Mailing Address - Phone:208-385-7711
Mailing Address - Fax:
Practice Address - Street 1:6490 S MCCARRAN BLVD STE 16
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-6165
Practice Address - Country:US
Practice Address - Phone:208-385-7711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FUNCTIONAL MEDICINE OF IDAHO PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-02-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty