Provider Demographics
NPI:1275999419
Name:PROFORM PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:PROFORM PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:978-255-4238
Mailing Address - Street 1:175 ELM ST UNIT C
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01952-1827
Mailing Address - Country:US
Mailing Address - Phone:978-255-4238
Mailing Address - Fax:978-473-7543
Practice Address - Street 1:175 ELM ST UNIT C
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MA
Practice Address - Zip Code:01952-1827
Practice Address - Country:US
Practice Address - Phone:978-255-4238
Practice Address - Fax:978-473-7543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-04
Last Update Date:2021-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20821225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty