Healthcare Provider Details

I. General information

NPI: 1932914389
Provider Name (Legal Business Name): FORM AND FUNCTION HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2025
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4278 INDIANOLA AVE
COLUMBUS OH
43214-2806
US

IV. Provider business mailing address

4278 INDIANOLA AVE
COLUMBUS OH
43214-2806
US

V. Phone/Fax

Practice location:
  • Phone: 419-235-2823
  • Fax:
Mailing address:
  • Phone: 419-235-2823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN P BELL II
Title or Position: VP FINANCE
Credential:
Phone: 419-235-2823