Provider Demographics
NPI:1285201392
Name:DYNAMIC PHYSICAL THERAPY AND WELLNESS LLC
Entity Type:Organization
Organization Name:DYNAMIC PHYSICAL THERAPY AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MERCADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-564-7515
Mailing Address - Street 1:220 LIVINGSTON ST STE 108
Mailing Address - Street 2:
Mailing Address - City:NORTHVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07647-1739
Mailing Address - Country:US
Mailing Address - Phone:120-189-5953
Mailing Address - Fax:201-564-7514
Practice Address - Street 1:185 CENTRAL AVE STE 311
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-3318
Practice Address - Country:US
Practice Address - Phone:201-564-7515
Practice Address - Fax:201-564-7514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1891017034OtherNPI