Provider Demographics
NPI:1750661542
Name:FUNCTIONAL DIMENSIONS LLC
Entity Type:Organization
Organization Name:FUNCTIONAL DIMENSIONS LLC
Other - Org Name:SUPERIOR PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:GORECKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-649-2015
Mailing Address - Street 1:3899 W. FRONT ST. UNIT #3
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684
Mailing Address - Country:US
Mailing Address - Phone:231-649-2015
Mailing Address - Fax:231-421-8447
Practice Address - Street 1:3899 W. FRONT ST. UNIT #3
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684
Practice Address - Country:US
Practice Address - Phone:231-649-2015
Practice Address - Fax:231-421-8447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2021-01-12
Deactivation Date:2020-12-03
Deactivation Code:
Reactivation Date:2021-01-12
Provider Licenses
StateLicense IDTaxonomies
MI5501014611225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI4468Medicare PIN