Provider Demographics
NPI:1730450990
Name:ADVANCED FUNCTIONAL HEALTH AND WELLNESS
Entity type:Organization
Organization Name:ADVANCED FUNCTIONAL HEALTH AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GBONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-426-3133
Mailing Address - Street 1:3731 SPICEBUSH DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21704-7879
Mailing Address - Country:US
Mailing Address - Phone:301-966-2558
Mailing Address - Fax:301-769-6650
Practice Address - Street 1:9711 WASHINGTONIAN BLVD STE 550
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878-5789
Practice Address - Country:US
Practice Address - Phone:301-966-2558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-19
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0069829261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care