Provider Demographics
NPI:1699140046
Name:RE-FORM PHYSICAL THERAPY AND PILATES, LLC
Entity type:Organization
Organization Name:RE-FORM PHYSICAL THERAPY AND PILATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENTRY
Authorized Official - Middle Name:ELISE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:806-803-9517
Mailing Address - Street 1:1916 S CAROLINA ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79102-2106
Mailing Address - Country:US
Mailing Address - Phone:806-803-9517
Mailing Address - Fax:
Practice Address - Street 1:1916 S CAROLINA ST
Practice Address - Street 2:SUITE 100
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79102-2106
Practice Address - Country:US
Practice Address - Phone:806-803-9517
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-10
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy