Provider Demographics
NPI:1245661024
Name:FORM AND FUNCTION PHYSICAL THERAPY P.C.
Entity type:Organization
Organization Name:FORM AND FUNCTION PHYSICAL THERAPY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:
Authorized Official - Last Name:FIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-619-2885
Mailing Address - Street 1:PO BOX 896
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-0030
Mailing Address - Country:US
Mailing Address - Phone:888-619-2885
Mailing Address - Fax:909-784-1995
Practice Address - Street 1:12067 ARROW RTE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-9219
Practice Address - Country:US
Practice Address - Phone:888-619-2885
Practice Address - Fax:909-784-1995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-04
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy