Provider Demographics
NPI:1487647004
Name:DYNAMIC PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:DYNAMIC PHYSICAL THERAPY INC
Other - Org Name:FYZICAL THERAPY AND BALANCE CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PT
Authorized Official - Prefix:MR
Authorized Official - First Name:LINCOLN
Authorized Official - Middle Name:NATHANIEL
Authorized Official - Last Name:KINKADE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:304-225-5222
Mailing Address - Street 1:746 FAIRMONT RD
Mailing Address - Street 2:
Mailing Address - City:WESTOVER
Mailing Address - State:WV
Mailing Address - Zip Code:26501-4060
Mailing Address - Country:US
Mailing Address - Phone:304-225-5222
Mailing Address - Fax:304-225-5224
Practice Address - Street 1:746 FAIRMONT RD
Practice Address - Street 2:
Practice Address - City:WESTOVER
Practice Address - State:WV
Practice Address - Zip Code:26501-4060
Practice Address - Country:US
Practice Address - Phone:304-225-5222
Practice Address - Fax:304-225-5224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-30
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810002407Medicaid
09043124OtherBCBS
WV3810002407Medicaid
09043124OtherBCBS
WV9335682Medicare PIN
WV9335681Medicare PIN