Provider Demographics
NPI:1124646294
Name:FUNCTION AND FORM PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:FUNCTION AND FORM PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:DELGADO
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:915-777-1749
Mailing Address - Street 1:5312 RIO BRAVO DR STE 7
Mailing Address - Street 2:
Mailing Address - City:SANTA TERESA
Mailing Address - State:NM
Mailing Address - Zip Code:88008-9210
Mailing Address - Country:US
Mailing Address - Phone:575-201-3764
Mailing Address - Fax:
Practice Address - Street 1:5312 RIO BRAVO DR STE 7
Practice Address - Street 2:
Practice Address - City:SANTA TERESA
Practice Address - State:NM
Practice Address - Zip Code:88008-9210
Practice Address - Country:US
Practice Address - Phone:575-201-3764
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-06
Last Update Date:2021-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty