Provider Demographics
NPI:1487185401
Name:FUNCTIONAL MEDICINE CENTERS
Entity Type:Organization
Organization Name:FUNCTIONAL MEDICINE CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-880-0685
Mailing Address - Street 1:481 HACKENSACK AVE
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-6330
Mailing Address - Country:US
Mailing Address - Phone:201-880-0685
Mailing Address - Fax:201-342-4346
Practice Address - Street 1:481 HACKENSACK AVE
Practice Address - Street 2:SUITE 2A
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-6330
Practice Address - Country:US
Practice Address - Phone:201-880-0685
Practice Address - Fax:201-342-4346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00080100363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty