Provider Demographics
NPI:1922237536
Name:FUNCTIONAL HEALTH, LLC
Entity Type:Organization
Organization Name:FUNCTIONAL HEALTH, LLC
Other - Org Name:MIDWEST SKIN INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KAHRE
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:812-491-6772
Mailing Address - Street 1:8601 N KENTUCKY AVE
Mailing Address - Street 2:SUITE I
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47725-6371
Mailing Address - Country:US
Mailing Address - Phone:812-491-6772
Mailing Address - Fax:812-491-0758
Practice Address - Street 1:8601 N KENTUCKY AVE
Practice Address - Street 2:SUITE I
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47725-6371
Practice Address - Country:US
Practice Address - Phone:812-491-6772
Practice Address - Fax:812-491-0758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-06
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001222A261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care