Provider Demographics
NPI:1366031973
Name:ADVANCED FUNCTIONAL HEALTH AND WELLNESS, LLC.
Entity Type:Organization
Organization Name:ADVANCED FUNCTIONAL HEALTH AND WELLNESS, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GBONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-966-2558
Mailing Address - Street 1:1003 W 7TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-4153
Mailing Address - Country:US
Mailing Address - Phone:301-966-2558
Mailing Address - Fax:
Practice Address - Street 1:1003 W 7TH ST STE B
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-4153
Practice Address - Country:US
Practice Address - Phone:301-966-2558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-18
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service