Provider Demographics
NPI:1083916787
Name:DYNAMIC PEDIATRIC THERAPY, INC.
Entity Type:Organization
Organization Name:DYNAMIC PEDIATRIC THERAPY, INC.
Other - Org Name:DYNAMIC THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ILEANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-242-9424
Mailing Address - Street 1:3581 NE 11 DR
Mailing Address - Street 2:NONE
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033
Mailing Address - Country:US
Mailing Address - Phone:954-682-7633
Mailing Address - Fax:
Practice Address - Street 1:15600 SW 288TH ST STE 202
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-1200
Practice Address - Country:US
Practice Address - Phone:305-242-9424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-01
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA11461171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001392900Medicaid