Provider Demographics
NPI:1437652476
Name:DYNAMIC PEAK PHYSICAL THERAPY PT PTA
Entity Type:Organization
Organization Name:DYNAMIC PEAK PHYSICAL THERAPY PT PTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DERILO
Authorized Official - Last Name:MIRABUENO
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:732-407-6308
Mailing Address - Street 1:75 ORIENT WAY STE 301
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07070-2086
Mailing Address - Country:US
Mailing Address - Phone:201-351-3055
Mailing Address - Fax:201-351-3184
Practice Address - Street 1:75 ORIENT WAY STE 301
Practice Address - Street 2:
Practice Address - City:RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07070-2086
Practice Address - Country:US
Practice Address - Phone:201-351-3055
Practice Address - Fax:201-351-3184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-15
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X, 171100000X
NJ40QA01300700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty