Provider Demographics
NPI:1568767309
Name:FUNCTION FOR LIFE PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:FUNCTION FOR LIFE PHYSICAL THERAPY, INC.
Other - Org Name:LONGEVITY PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:760-918-9200
Mailing Address - Street 1:1084 N EL CAMINO REAL # B-351
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-1334
Mailing Address - Country:US
Mailing Address - Phone:760-918-9200
Mailing Address - Fax:760-918-9203
Practice Address - Street 1:2719 LOKER AVE W STE A
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92010-6679
Practice Address - Country:US
Practice Address - Phone:760-918-9200
Practice Address - Fax:760-918-9203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty