Provider Demographics
NPI:1124533856
Name:FUNCTIONAL HEALTH INSTITUTE, INC
Entity type:Organization
Organization Name:FUNCTIONAL HEALTH INSTITUTE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:W
Authorized Official - Last Name:FENTRESS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:386-673-2000
Mailing Address - Street 1:132 N NOVA RD
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5122
Mailing Address - Country:US
Mailing Address - Phone:386-673-2000
Mailing Address - Fax:386-673-2002
Practice Address - Street 1:132 N NOVA RD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5122
Practice Address - Country:US
Practice Address - Phone:386-673-2000
Practice Address - Fax:386-673-2002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH11802FL111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Single Specialty