Provider Demographics
NPI:1376637454
Name:DYNAMIC PHYSICAL THERAPY & REHABILITATION CENTER LLC
Entity Type:Organization
Organization Name:DYNAMIC PHYSICAL THERAPY & REHABILITATION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:SALAMANCA
Authorized Official - Last Name:STO.DOMINGO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:843-910-4093
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 1:2307 E HIGHWAY 76
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:SC
Practice Address - Zip Code:29571-6351
Practice Address - Country:US
Practice Address - Phone:843-423-4888
Practice Address - Fax:843-423-4849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2466225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8610Medicare PIN