Provider Demographics
NPI:1720783665
Name:FUNCTIONAL WELLNESS LLC
Entity Type:Organization
Organization Name:FUNCTIONAL WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:LD
Authorized Official - Phone:405-277-0144
Mailing Address - Street 1:1 NE 2ND ST APT 401
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-2236
Mailing Address - Country:US
Mailing Address - Phone:405-277-0144
Mailing Address - Fax:
Practice Address - Street 1:1611 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-4610
Practice Address - Country:US
Practice Address - Phone:405-277-0144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-31
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty