Provider Demographics
NPI:1083968929
Name:FUNCTIONAL MOVEMENT REHAB AND FITNESS, INC.
Entity Type:Organization
Organization Name:FUNCTIONAL MOVEMENT REHAB AND FITNESS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERRA
Authorized Official - Middle Name:
Authorized Official - Last Name:YASKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MOTR/L
Authorized Official - Phone:561-723-8437
Mailing Address - Street 1:2459 CARDINAL LN
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-1223
Mailing Address - Country:US
Mailing Address - Phone:561-723-8437
Mailing Address - Fax:
Practice Address - Street 1:2459 CARDINAL LN
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-1223
Practice Address - Country:US
Practice Address - Phone:561-723-8437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-30
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT17788225100000X, 2251S0007X, 2251X0800X
FLOT9985225X00000X
FL1061101186225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBN755ZOtherMEDICARE PTAN
FLEN537ZOtherMEDICARE PTAN