Provider Demographics
NPI:1407073299
Name:DYNAMIC MEDICAL REHABILITATION CENTER OF DEERFIELD BEACH
Entity Type:Organization
Organization Name:DYNAMIC MEDICAL REHABILITATION CENTER OF DEERFIELD BEACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BASTKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-421-2005
Mailing Address - Street 1:342 S POWERLINE RD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33442-8105
Mailing Address - Country:US
Mailing Address - Phone:954-421-2005
Mailing Address - Fax:954-421-4285
Practice Address - Street 1:342 S POWERLINE RD
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33442-8105
Practice Address - Country:US
Practice Address - Phone:954-421-2005
Practice Address - Fax:954-421-4285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7166111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL77325AOtherBCBS
FL55528Medicare ID - Type Unspecified