Provider Demographics
NPI:1043999196
Name:FORM FUNCTIONAL HEALTH LLC
Entity Type:Organization
Organization Name:FORM FUNCTIONAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAFFAELE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAGONIGRO
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:973-464-6356
Mailing Address - Street 1:15 GODWIN AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-3739
Mailing Address - Country:US
Mailing Address - Phone:973-841-4800
Mailing Address - Fax:
Practice Address - Street 1:15 GODWIN AVE STE 1
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3739
Practice Address - Country:US
Practice Address - Phone:973-841-4800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-17
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy