Provider Demographics
NPI:1043315161
Name:DYNAMIC REHABILITATION
Entity Type:Organization
Organization Name:DYNAMIC REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:RONALDO
Authorized Official - Last Name:ELUMBA
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:949-300-3423
Mailing Address - Street 1:28 STYLE DR
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-8090
Mailing Address - Country:US
Mailing Address - Phone:949-300-1105
Mailing Address - Fax:949-215-1961
Practice Address - Street 1:28 STYLE DR
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-8090
Practice Address - Country:US
Practice Address - Phone:949-300-1105
Practice Address - Fax:949-215-1961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT22423225100000X, 2251E1200X, 2251N0400X, 2251X0800X, 2251N0400X
225100000X
CAOT2859225XN1300X, 225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomicsGroup - Multi-Specialty
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurologyGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitationGroup - Multi-Specialty
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ69019ZOtherBLUE SHIELD GROUP ID