Provider Demographics
NPI:1356178271
Name:FORM X FUNCTION WELLNESS, LLC
Entity type:Organization
Organization Name:FORM X FUNCTION WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:PELICANO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:864-293-4213
Mailing Address - Street 1:420 PEACH GROVE PL
Mailing Address - Street 2:
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-3406
Mailing Address - Country:US
Mailing Address - Phone:864-293-4213
Mailing Address - Fax:
Practice Address - Street 1:6 SEVIER ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605
Practice Address - Country:US
Practice Address - Phone:864-214-6163
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty