Provider Demographics
NPI:1023359957
Name:FUNCTIONAL CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:FUNCTIONAL CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:REES
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:410-430-9061
Mailing Address - Street 1:611 FEDERAL ST
Mailing Address - Street 2:STE 5
Mailing Address - City:MILTON
Mailing Address - State:DE
Mailing Address - Zip Code:19968-1157
Mailing Address - Country:US
Mailing Address - Phone:302-684-1995
Mailing Address - Fax:302-329-9743
Practice Address - Street 1:611 FEDERAL ST
Practice Address - Street 2:STE 5
Practice Address - City:MILTON
Practice Address - State:DE
Practice Address - Zip Code:19968-1157
Practice Address - Country:US
Practice Address - Phone:302-684-1995
Practice Address - Fax:302-329-9743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-01
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEF1-0000735111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty