Provider Demographics
NPI:1164626925
Name:DYNAMIC PHYSICAL THERAPY & REHABILITATION
Entity Type:Organization
Organization Name:DYNAMIC PHYSICAL THERAPY & REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:CARBONEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-331-0919
Mailing Address - Street 1:PO BOX 1864
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29602-1864
Mailing Address - Country:US
Mailing Address - Phone:864-331-0919
Mailing Address - Fax:864-331-0922
Practice Address - Street 1:9789 CHARLOTTE HWY
Practice Address - Street 2:SUITE 500
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-7177
Practice Address - Country:US
Practice Address - Phone:803-548-5022
Practice Address - Fax:803-548-5023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8610Medicare PIN