MEDICARE: FUNCTION BUILDER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1518508688
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FUNCTION BUILDER LLC

Provider Business Mailing Address
First Line	:	7210 164TH ST
Second Line	:
City	:	FRESH MEADOWS
State	:	NY
Zip	:	11365-4222
Country	:	US
Telephone Number	:	718-591-2064
Fax Number	:	718-591-2064

Provider Business Practice Location Address
First Line	:	7210 164TH ST
Second Line	:
City	:	FRESH MEADOWS
State	:	NY
Zip	:	11365-4222
Country	:	US
Telephone Number	:	718-591-2064
Fax Number	:	718-591-2064

Authorized Official
Title or Position	:	PHYSICAL THERAPIST
Name	:	MARIA JUSON
Credential	:	P.T.
Telephone Number	:	917-293-8821

Provider Enumeration Date	:	09/30/2019
Last Update Date	:	09/30/2019

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Directions to “FUNCTION BUILDER LLC ” Practice Location

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