Provider Demographics
NPI:1235488354
Name:FUNCTIONAL THERAPEUTICS
Entity Type:Organization
Organization Name:FUNCTIONAL THERAPEUTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUVENTINO
Authorized Official - Middle Name:
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:SLP
Authorized Official - Phone:956-533-4390
Mailing Address - Street 1:616 VIDA SANTA ST
Mailing Address - Street 2:
Mailing Address - City:ALAMO
Mailing Address - State:TX
Mailing Address - Zip Code:78516
Mailing Address - Country:US
Mailing Address - Phone:956-533-4390
Mailing Address - Fax:956-587-0245
Practice Address - Street 1:616 VIDA SANTA ST
Practice Address - Street 2:
Practice Address - City:ALAMO
Practice Address - State:TX
Practice Address - Zip Code:78516
Practice Address - Country:US
Practice Address - Phone:956-533-4390
Practice Address - Fax:956-587-0245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111838235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty