Provider Demographics
NPI:1952141475
Name:FUNCTIONALCARE 360
Entity type:Organization
Organization Name:FUNCTIONALCARE 360
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JARRED
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:331-442-5062
Mailing Address - Street 1:9828 AINSLIE DOWNS ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-4976
Mailing Address - Country:US
Mailing Address - Phone:331-442-5062
Mailing Address - Fax:681-201-0332
Practice Address - Street 1:9828 AINSLIE DOWNS ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-4976
Practice Address - Country:US
Practice Address - Phone:331-442-5062
Practice Address - Fax:681-201-0332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-31
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care