Provider Demographics
NPI:1053085092
Name:FUNCTIONAL HOME THERAPY SERVICES LLC
Entity Type:Organization
Organization Name:FUNCTIONAL HOME THERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:NENE
Authorized Official - Last Name:BACOLOD
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPT
Authorized Official - Phone:856-506-6281
Mailing Address - Street 1:1616 HAMILTON ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-5346
Mailing Address - Country:US
Mailing Address - Phone:856-506-6281
Mailing Address - Fax:
Practice Address - Street 1:1616 HAMILTON ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-5346
Practice Address - Country:US
Practice Address - Phone:856-506-6281
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-03
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1972558260Medicaid