Healthcare Provider Details

I. General information

NPI: 1093727802
Provider Name (Legal Business Name): FUNCTIONAL INNOVATIVE THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3035 HOAG AVE NE
GRAND RAPIDS MI
49525-9632
US

IV. Provider business mailing address

3035 HOAG AVE NE
GRAND RAPIDS MI
49525-9632
US

V. Phone/Fax

Practice location:
  • Phone: 616-365-9394
  • Fax: 616-365-9394
Mailing address:
  • Phone: 616-365-9394
  • Fax: 616-365-9394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number5501012424
License Number StateMI

VIII. Authorized Official

Name: DR. TREY JOSEPH KUBIZNA
Title or Position: MEMBER
Credential: DPT
Phone: 616-365-9394