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General NPI Number Information
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NPI Number | 1124646294
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Entity Type | Organization
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Legal Business Name | FUNCTION AND FORM PHYSICAL THERAPY LLC
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Dates
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Enumeration Date | 07/06/2020
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Last Update Date | 03/28/2021
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Provider Practice Location Address
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Address Line | 5312 RIO BRAVO DR STE 7
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City | SANTA TERESA
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State | NM
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Zip | 88008-9210
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Country | US
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Telephone | 575-201-3764
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Fax |
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Provider Business Mailing Address
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Address Line | 5312 RIO BRAVO DR STE 7
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City | SANTA TERESA
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State | NM
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Zip | 88008-9210
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Country | US
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Telephone | 575-201-3764
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | DERRICK DELGADO
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Credential | PTA
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Telephone | 915-777-1749
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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