Healthcare Provider Details

I. General information

NPI: 1083968929
Provider Name (Legal Business Name): FUNCTIONAL MOVEMENT REHAB AND FITNESS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2012
Last Update Date: 10/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2459 CARDINAL LN
PALM BEACH GARDENS FL
33410-1223
US

IV. Provider business mailing address

2459 CARDINAL LN
PALM BEACH GARDENS FL
33410-1223
US

V. Phone/Fax

Practice location:
  • Phone: 561-723-8437
  • Fax:
Mailing address:
  • Phone: 561-723-8437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT17788
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPT17788
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT17788
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT9985
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number1061101186
License Number StateFL

VIII. Authorized Official

Name: MRS. TERRA YASKIN
Title or Position: VICE PRESIDENT
Credential: M.OTR/L
Phone: 561-723-8437