Provider Demographics
NPI:1144840414
Name:FUNCTIONAL THERAPY AND WELLNESS LLC
Entity type:Organization
Organization Name:FUNCTIONAL THERAPY AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF PHYSICAL THERAPY
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:H
Authorized Official - Last Name:ROSONINA
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:321-202-3323
Mailing Address - Street 1:2715 KNOX MCRAE DR
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-5113
Mailing Address - Country:US
Mailing Address - Phone:321-202-3323
Mailing Address - Fax:
Practice Address - Street 1:2715 KNOX MCRAE DR
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-5113
Practice Address - Country:US
Practice Address - Phone:321-202-3323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-16
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy