=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699473686
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FORM & FUNCTION FYZIO PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2023
-----------------------------------------------------
Last Update Date | 02/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1021 11TH ST SW
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34117-2298
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-944-1597
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1021 11TH ST SW
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34117-2298
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-944-1597
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | JAMES RYAN SAUERWALD
-----------------------------------------------------
Credential | PT, DPT, AIB-VRC
-----------------------------------------------------
Telephone | 239-944-1597
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------