Provider Demographics
NPI:1164962932
Name:FUNCTIONAL MEDICINE SPECIALISTS
Entity Type:Organization
Organization Name:FUNCTIONAL MEDICINE SPECIALISTS
Other - Org Name:FUNCTIONAL MEDICINE SPECIALISTS NURSING PRACTITIONER SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAMBRIA
Authorized Official - Middle Name:MARCY
Authorized Official - Last Name:DEMARCO PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:619-306-6949
Mailing Address - Street 1:2210 ENCINITAS BLVD STE T
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-4376
Mailing Address - Country:US
Mailing Address - Phone:760-270-3990
Mailing Address - Fax:
Practice Address - Street 1:2210 ENCINITAS BLVD STE T
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-4376
Practice Address - Country:US
Practice Address - Phone:760-270-3990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA534073261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center