Provider Demographics
NPI:1932627312
Name:FUNCTIONAL RD, LLC
Entity Type:Organization
Organization Name:FUNCTIONAL RD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:AIMEE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:SENIOR
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LD
Authorized Official - Phone:210-920-0669
Mailing Address - Street 1:14439 NW MILITARY HWY STE 108
Mailing Address - Street 2:
Mailing Address - City:SHAVANO PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78231-1648
Mailing Address - Country:US
Mailing Address - Phone:210-920-0669
Mailing Address - Fax:210-920-6645
Practice Address - Street 1:106 CHIMNEY ROCK LANE
Practice Address - Street 2:
Practice Address - City:SHAVANO PARK
Practice Address - State:TX
Practice Address - Zip Code:78231-1648
Practice Address - Country:US
Practice Address - Phone:409-658-5028
Practice Address - Fax:210-920-6645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-06
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT83404133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty