MEDICARE: PROFORM PHYSICAL THERAPY LLC

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	:	1861047854
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFORM PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	1212 HIGHWAY 34 STE 24-25
Second Line	:
City	:	MATAWAN
State	:	NJ
Zip	:	07747-1903
Country	:	US
Telephone Number	:	732-970-7882
Fax Number	:	732-970-7883

Provider Business Practice Location Address
First Line	:	1921 ROUTE 27
Second Line	:
City	:	EDISON
State	:	NJ
Zip	:	08817-3250
Country	:	US
Telephone Number	:	732-970-7882
Fax Number	:	732-970-7883

Authorized Official
Title or Position	:	OWNER
Name	:	LEONARD JESUS SOMARRIBA
Credential	:	PT
Telephone Number	:	561-676-3565

Provider Enumeration Date	:	08/06/2019
Last Update Date	:	08/06/2019

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Directions to “PROFORM PHYSICAL THERAPY LLC ” Practice Location

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