Provider Demographics
NPI:1194402180
Name:OPTIMAL FORM & FUNCTION, LLC
Entity type:Organization
Organization Name:OPTIMAL FORM & FUNCTION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FORMISANO
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, OCS
Authorized Official - Phone:201-817-9976
Mailing Address - Street 1:3-18 VIRGINIA DR APT A
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-4727
Mailing Address - Country:US
Mailing Address - Phone:201-887-2409
Mailing Address - Fax:
Practice Address - Street 1:1029 TEANECK RD STE 2E
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4514
Practice Address - Country:US
Practice Address - Phone:551-246-9340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-30
Last Update Date:2023-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty