Provider Demographics
NPI:1164564688
Name:DYNAMICS WALKAGAIN REHAB INC.
Entity Type:Organization
Organization Name:DYNAMICS WALKAGAIN REHAB INC.
Other - Org Name:DYNAMICS SPINAL CORD REHAB UNIT
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:SEAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:213-383-6860
Mailing Address - Street 1:1830 W OLYMPIC BLVD STE 123
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-3734
Mailing Address - Country:US
Mailing Address - Phone:213-383-6860
Mailing Address - Fax:213-383-6421
Practice Address - Street 1:1830 W OLYMPIC BLVD
Practice Address - Street 2:STE 130
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-3734
Practice Address - Country:US
Practice Address - Phone:213-383-6860
Practice Address - Fax:213-383-6421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGPT000880225100000X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGPT000880Medicaid
CAGPT000880Medicaid