MEDICARE: FUNCTIONA; PHYSICAL FITNESS

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	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1790640829
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FUNCTIONA; PHYSICAL FITNESS

Provider Business Mailing Address
First Line	:	409 S GOMEZ AVE APT 1
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33609-4194
Country	:	US
Telephone Number	:	959-200-2267
Fax Number	:

Provider Business Practice Location Address
First Line	:	409 S GOMEZ AVE APT 1
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33609-4194
Country	:	US
Telephone Number	:	959-200-2267
Fax Number	:

Authorized Official
Title or Position	:	FOUNDER/PHYSICAL THERAPIST
Name	:	JIA GATES
Credential	:
Telephone Number	:	959-200-2267

Provider Enumeration Date	:	12/20/2025
Last Update Date	:	12/20/2025

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