Provider Demographics
NPI:1578265476
Name:FORM AND FUNCTION PHYSICAL THERAPY PLLC
Entity Type:Organization
Organization Name:FORM AND FUNCTION PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PRATIK
Authorized Official - Middle Name:C
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:804-564-5194
Mailing Address - Street 1:11411 HUNTON COTTAGE CT
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-4848
Mailing Address - Country:US
Mailing Address - Phone:804-564-5194
Mailing Address - Fax:
Practice Address - Street 1:11411 HUNTON COTTAGE CT
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-4848
Practice Address - Country:US
Practice Address - Phone:804-564-5194
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-22
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy