MEDICARE: FORM PHYSICAL THERAPY LIFESTYLE WELLNESS PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1629903760
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORM PHYSICAL THERAPY LIFESTYLE WELLNESS PLLC

Provider Business Mailing Address
First Line	:	21426 41ST AVE STE 110
Second Line	:
City	:	BAYSIDE
State	:	NY
Zip	:	11361-2149
Country	:	US
Telephone Number	:	718-279-9800
Fax Number	:

Provider Business Practice Location Address
First Line	:	21426 41ST AVE STE 110
Second Line	:
City	:	BAYSIDE
State	:	NY
Zip	:	11361-2149
Country	:	US
Telephone Number	:	718-279-9800
Fax Number	:

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	DR. DAN THOMAS
Credential	:
Telephone Number	:	833-442-2053

Provider Enumeration Date	:	06/17/2026
Last Update Date	:	06/17/2026

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