Provider Demographics
NPI:1497191241
Name:FUNCTIONAL NEUROLOGY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:FUNCTIONAL NEUROLOGY ASSOCIATES, LLC
Other - Org Name:CHIROPRO PERFORMANCE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:M
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC, DACNB
Authorized Official - Phone:978-429-8952
Mailing Address - Street 1:30 GREAT ROAD
Mailing Address - Street 2:SUITE #103
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720
Mailing Address - Country:US
Mailing Address - Phone:978-429-8952
Mailing Address - Fax:978-429-8953
Practice Address - Street 1:30 GREAT ROAD
Practice Address - Street 2:SUITE #103
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720
Practice Address - Country:US
Practice Address - Phone:978-429-8952
Practice Address - Fax:978-429-8953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA111N00000X
MACH2739CH3404111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Single Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty