Provider Demographics
NPI:1194471722
Name:FUNDAMENTALS THERAPY GROUP CORP
Entity Type:Organization
Organization Name:FUNDAMENTALS THERAPY GROUP CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAYRA
Authorized Official - Middle Name:
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-343-7959
Mailing Address - Street 1:7826 NW 167TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-3422
Mailing Address - Country:US
Mailing Address - Phone:786-343-7959
Mailing Address - Fax:
Practice Address - Street 1:7826 NW 167TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33016-3422
Practice Address - Country:US
Practice Address - Phone:786-343-7959
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center