Provider Demographics
NPI:1063974152
Name:FEARLESS FUNCTIONAL FITNESS, LLC
Entity type:Organization
Organization Name:FEARLESS FUNCTIONAL FITNESS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:LAIRD
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:512-730-9600
Mailing Address - Street 1:324 RIVERWALK DR STE 312
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-6936
Mailing Address - Country:US
Mailing Address - Phone:512-268-9130
Mailing Address - Fax:833-437-4389
Practice Address - Street 1:324 RIVERWALK DR STE 312
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-6936
Practice Address - Country:US
Practice Address - Phone:512-268-9130
Practice Address - Fax:833-437-4389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-05
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty