Provider Demographics
NPI:1396414835
Name:FORM FIX LLC
Entity Type:Organization
Organization Name:FORM FIX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:201-306-2532
Mailing Address - Street 1:1168 LAKE AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-2745
Mailing Address - Country:US
Mailing Address - Phone:201-306-2532
Mailing Address - Fax:
Practice Address - Street 1:173 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-3789
Practice Address - Country:US
Practice Address - Phone:201-306-2532
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy