1689166571 NPI number — FUNCTIONALLY LIMITLESS, LLC

Table of content: (NPI 1689166571)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689166571 NPI number — FUNCTIONALLY LIMITLESS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FUNCTIONALLY LIMITLESS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LIMITLESS CONCIERGE PHYSICAL THERAPY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689166571
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2585 LYNWOOD PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERRITT ISLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32953-4163
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-325-9395
Provider Business Mailing Address Fax Number:
844-210-9901

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2425 N COURTENAY PKWY STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERRITT ISLAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32953-4181
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-795-4213
Provider Business Practice Location Address Fax Number:
844-210-9901
Provider Enumeration Date:
06/05/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BOERSMA
Authorized Official First Name:
TRAVIS
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
954-325-9395

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT26481 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 726167 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100748000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".