Provider Demographics
NPI:1366761520
Name:VISION OF HEALTH AND FUNCTIONAL MEDICINE PC
Entity type:Organization
Organization Name:VISION OF HEALTH AND FUNCTIONAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VERNON
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:PROCTOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-745-4914
Mailing Address - Street 1:1234 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:MI
Mailing Address - Zip Code:49304-7737
Mailing Address - Country:US
Mailing Address - Phone:231-745-4914
Mailing Address - Fax:269-745-4922
Practice Address - Street 1:1234 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:MI
Practice Address - Zip Code:49304-7737
Practice Address - Country:US
Practice Address - Phone:231-745-4914
Practice Address - Fax:269-745-4922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-26
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010893652083P0500X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Multi-Specialty