Provider Demographics
NPI:1477311090
Name:FUNCTIONAL LIFESTYLE SOLUTIONS
Entity Type:Organization
Organization Name:FUNCTIONAL LIFESTYLE SOLUTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLAS
Authorized Official - Suffix:
Authorized Official - Credentials:COTA
Authorized Official - Phone:937-312-4441
Mailing Address - Street 1:608 JUDITH DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5312
Mailing Address - Country:US
Mailing Address - Phone:937-312-4441
Mailing Address - Fax:
Practice Address - Street 1:608 JUDITH DR
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-5312
Practice Address - Country:US
Practice Address - Phone:937-312-4441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care