Provider Demographics
NPI:1396917738
Name:FUNK, LEE W (DC, CCEP, AP, DOM)
Entity type:Individual
Prefix:DR
First Name:LEE
Middle Name:W
Last Name:FUNK
Suffix:
Gender:M
Credentials:DC, CCEP, AP, DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 US HIGHWAY 1
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-1611
Mailing Address - Country:US
Mailing Address - Phone:772-581-3773
Mailing Address - Fax:772-581-3746
Practice Address - Street 1:1511 US HIGHWAY 1
Practice Address - Street 2:SUITE 203
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-1611
Practice Address - Country:US
Practice Address - Phone:772-581-3773
Practice Address - Fax:772-581-3746
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0006567111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22945OtherBLUE CROSS BLUE SHIELD
FL22945OtherBLUE CROSS BLUE SHIELD