Provider Demographics
NPI:1154915205
Name:PINE FORREST FUNCTIONAL MEDICINE
Entity type:Organization
Organization Name:PINE FORREST FUNCTIONAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THU
Authorized Official - Middle Name:ANH
Authorized Official - Last Name:HOANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-743-5136
Mailing Address - Street 1:20111 IRONHARP DR
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77379-1975
Mailing Address - Country:US
Mailing Address - Phone:972-743-5136
Mailing Address - Fax:
Practice Address - Street 1:150 PINE FOREST DR STE 701
Practice Address - Street 2:
Practice Address - City:WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77384-5317
Practice Address - Country:US
Practice Address - Phone:972-743-5136
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty