Provider Demographics
NPI:1144054123
Name:GAIA FUNCTIONAL MEDICINE
Entity type:Organization
Organization Name:GAIA FUNCTIONAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:OLAVARRIA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:772-356-0620
Mailing Address - Street 1:701 21ST ST STE 101
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-5419
Mailing Address - Country:US
Mailing Address - Phone:772-356-0620
Mailing Address - Fax:
Practice Address - Street 1:701 21ST ST STE 101
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-5419
Practice Address - Country:US
Practice Address - Phone:772-356-0620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-30
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202D00000XAllopathic & Osteopathic PhysiciansIntegrative MedicineGroup - Single Specialty