Provider Demographics
NPI:1376917591
Name:FUNCTION & HEALTH PROFESSIONALS LLC
Entity Type:Organization
Organization Name:FUNCTION & HEALTH PROFESSIONALS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIQUELLA
Authorized Official - Middle Name:SHANTEL
Authorized Official - Last Name:KING-WHITBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DABMA
Authorized Official - Phone:404-449-0545
Mailing Address - Street 1:PO BOX 20731
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31205-0731
Mailing Address - Country:US
Mailing Address - Phone:478-292-2060
Mailing Address - Fax:877-991-6389
Practice Address - Street 1:685 ARLINGTON PL
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1772
Practice Address - Country:US
Practice Address - Phone:478-292-2060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-27
Last Update Date:2015-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA58891261QM2500X, 261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation