Basic Information
| Provider Information | |||||||||
| NPI: | 1568775161 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FUNCTIONMD MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 S HICKORY ST | ||||||||
| Address2: | SUITE 118 | ||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920254359 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 215 S HICKORY ST | ||||||||
| Address2: | SUITE 118 | ||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920254359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604326644 | ||||||||
| FaxNumber: | 7607398213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2010 | ||||||||
| LastUpdateDate: | 09/07/2010 | ||||||||
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| AuthorizedOfficialLastName: | CHEN | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9496828020 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | A102762 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.