MEDICARE: FULL FUNCTION PHYSICAL THERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	163WM1400X	Nurse Massage Therapist (NMT)
2	225200000X	Physical Therapy Assistant
3	225700000X	Massage Therapist
4	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1043955099
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULL FUNCTION PHYSICAL THERAPY, LLC

Provider Business Mailing Address
First Line	:	124 SOARING SKY AVE
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89011-2535
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2250 CORPORATE CIR STE 350
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89074-7714
Country	:	US
Telephone Number	:	702-522-7858
Fax Number	:	702-522-7897

Authorized Official
Title or Position	:	CREDENTIALER
Name	:	SANDY FRIDAY
Credential	:
Telephone Number	:	702-800-8988

Provider Enumeration Date	:	05/04/2022
Last Update Date	:	08/12/2022

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