Healthcare Provider Details

I. General information

NPI: 1194402180
Provider Name (Legal Business Name): OPTIMAL FORM & FUNCTION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2023
Last Update Date: 12/16/2023
Certification Date: 12/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1029 TEANECK RD STE 2E
TEANECK NJ
07666-4514
US

IV. Provider business mailing address

3-18 VIRGINIA DR APT A
FAIR LAWN NJ
07410-4727
US

V. Phone/Fax

Practice location:
  • Phone: 551-246-9340
  • Fax:
Mailing address:
  • Phone: 201-887-2409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. MICHAEL FORMISANO
Title or Position: FOUNDER/PHYSICAL THERAPIST
Credential: PT, DPT, OCS
Phone: 201-817-9976