MEDICARE: FUNCTIONAL MOVEMENT PHYSICAL THERAPY

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	:	1871119891
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FUNCTIONAL MOVEMENT PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	6299 DRAKE SETTLEMENT RD
Second Line	:
City	:	BURT
State	:	NY
Zip	:	14028-9718
Country	:	US
Telephone Number	:	361-774-2467
Fax Number	:	888-384-2408

Provider Business Practice Location Address
First Line	:	6299 DRAKE SETTLEMENT RD
Second Line	:
City	:	BURT
State	:	NY
Zip	:	14028-9718
Country	:	US
Telephone Number	:	361-774-2467
Fax Number	:	888-384-2408

Authorized Official
Title or Position	:	PHYSICAL THERAPY/OWNER
Name	:	NICHOLAUS RENE SALINAS
Credential	:	DPT
Telephone Number	:	361-774-2467

Provider Enumeration Date	:	06/25/2020
Last Update Date	:	06/25/2020

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