Provider Demographics
NPI:1073270997
Name:AMBROSIA FUNCTIONAL MEDICINE LLC
Entity Type:Organization
Organization Name:AMBROSIA FUNCTIONAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHIBUZOR
Authorized Official - Middle Name:STEVE
Authorized Official - Last Name:EKE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:770-866-7016
Mailing Address - Street 1:PO BOX 1415
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-1167
Mailing Address - Country:US
Mailing Address - Phone:770-866-7016
Mailing Address - Fax:
Practice Address - Street 1:480 E PACES FERRY RD NE STE 8
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-3324
Practice Address - Country:US
Practice Address - Phone:770-866-7016
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-27
Last Update Date:2021-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1134670474Medicaid