Provider Demographics
NPI:1164284964
Name:FUNCTIONAL MEDICINE 1 PLLC
Entity Type:Organization
Organization Name:FUNCTIONAL MEDICINE 1 PLLC
Other - Org Name:ADVANCED URGENT CARE & WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:GATES
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICIAN ASSISTANT
Authorized Official - Phone:704-214-0935
Mailing Address - Street 1:111 DAVE WARLICK DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLNTON
Mailing Address - State:NC
Mailing Address - Zip Code:28092-4411
Mailing Address - Country:US
Mailing Address - Phone:704-214-0935
Mailing Address - Fax:
Practice Address - Street 1:111 DAVE WARLICK DR
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-4411
Practice Address - Country:US
Practice Address - Phone:704-240-8133
Practice Address - Fax:866-493-3890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-26
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202D00000XAllopathic & Osteopathic PhysiciansIntegrative MedicineGroup - Multi-Specialty