Provider Demographics
NPI:1407046881
Name:ADVANCED DYNAMIC THERAPIES PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:ADVANCED DYNAMIC THERAPIES PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:REDDICK
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:323-295-5836
Mailing Address - Street 1:644 E REGENT ST
Mailing Address - Street 2:101
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1433
Mailing Address - Country:US
Mailing Address - Phone:310-330-1177
Mailing Address - Fax:310-330-1188
Practice Address - Street 1:644 E REGENT ST
Practice Address - Street 2:101
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1433
Practice Address - Country:US
Practice Address - Phone:310-330-1177
Practice Address - Fax:310-330-1188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT16833225100000X
CA49951332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT16833Medicare UPIN
CA6164700001Medicare NSC