Provider Demographics
NPI:1194430371
Name:CENTER FOR FUNCTIONAL MEDICINE AND ULTIMATE WELLNESS
Entity type:Organization
Organization Name:CENTER FOR FUNCTIONAL MEDICINE AND ULTIMATE WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BYRON
Authorized Official - Last Name:MCCLAIN
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:936-240-0530
Mailing Address - Street 1:1607 ARROWHEAD DR
Mailing Address - Street 2:
Mailing Address - City:PANTEGO
Mailing Address - State:TX
Mailing Address - Zip Code:76013-3012
Mailing Address - Country:US
Mailing Address - Phone:936-240-0530
Mailing Address - Fax:682-238-3509
Practice Address - Street 1:615 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-5450
Practice Address - Country:US
Practice Address - Phone:817-764-1148
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty