Provider Demographics
NPI:1114529237
Name:FUNDAMENTAL HEALTH, INC
Entity Type:Organization
Organization Name:FUNDAMENTAL HEALTH, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:765-838-2310
Mailing Address - Street 1:1221 S CREASY LN STE K3
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-7430
Mailing Address - Country:US
Mailing Address - Phone:765-838-2310
Mailing Address - Fax:765-838-1035
Practice Address - Street 1:1221 S CREASY LN STE K3
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-7430
Practice Address - Country:US
Practice Address - Phone:765-838-2310
Practice Address - Fax:765-838-1035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-13
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1942753082OtherNPI
IN1114529237OtherMEN'S HEALTH
IN1659312759OtherNPI