Provider Demographics
NPI:1629486550
Name:FORM & FUNCTION PHYSICAL THERAPY AND SPORTS MEDICINE LLC
Entity Type:Organization
Organization Name:FORM & FUNCTION PHYSICAL THERAPY AND SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GUERRINO
Authorized Official - Middle Name:
Authorized Official - Last Name:BONI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-465-8244
Mailing Address - Street 1:250 SCRABBLETOWN RD
Mailing Address - Street 2:
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-3016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 SCRABBLETOWN RD
Practice Address - Street 2:
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-3016
Practice Address - Country:US
Practice Address - Phone:617-326-3008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-23
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT01838174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty