Provider Demographics
NPI:1518138254
Name:CENTER FOR FUNCTIONAL & INTEGRATIVE MEDICINE, INC
Entity Type:Organization
Organization Name:CENTER FOR FUNCTIONAL & INTEGRATIVE MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:HOLTHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-306-2997
Mailing Address - Street 1:3104 PONTE MORINO DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CAMERON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:95682-8277
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3104 PONTE MORINO DR
Practice Address - Street 2:SUITE 110
Practice Address - City:CAMERON PARK
Practice Address - State:CA
Practice Address - Zip Code:95682-8277
Practice Address - Country:US
Practice Address - Phone:530-626-8300
Practice Address - Fax:530-626-7617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-21
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G757170Medicare PIN