Provider Demographics
NPI:1033646625
Name:PROFORM PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:PROFORM PHYSICAL THERAPY LLC
Other - Org Name:PROFYSIO PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SOMARRIBA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:732-970-7882
Mailing Address - Street 1:2665 HIGHWAY 516
Mailing Address - Street 2:SUITE 13/14
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-2300
Mailing Address - Country:US
Mailing Address - Phone:732-970-7882
Mailing Address - Fax:732-970-7883
Practice Address - Street 1:2665 HIGHWAY 516 STE 1314
Practice Address - Street 2:
Practice Address - City:OLD BRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08857-2300
Practice Address - Country:US
Practice Address - Phone:732-970-7882
Practice Address - Fax:732-970-7883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ171100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty