Provider Demographics
NPI:1407621964
Name:SAN ANTONIO FUNCTIONAL HEALTH PLLC
Entity type:Organization
Organization Name:SAN ANTONIO FUNCTIONAL HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:LISERIO
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:210-468-1891
Mailing Address - Street 1:1602 MCCULLOUGH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-4434
Mailing Address - Country:US
Mailing Address - Phone:210-468-1891
Mailing Address - Fax:210-568-4905
Practice Address - Street 1:1602 MCCULLOUGH AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-4434
Practice Address - Country:US
Practice Address - Phone:210-468-1891
Practice Address - Fax:210-568-4905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty