Provider Demographics
NPI:1558826644
Name:DYNAMIC PHYSICAL THERAPY AND SPORTS REHAB AT NEWARK
Entity Type:Organization
Organization Name:DYNAMIC PHYSICAL THERAPY AND SPORTS REHAB AT NEWARK
Other - Org Name:DYNAMIC PHYSICAL THERAPY AND SPORTS REHAB AT NEWARK
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MERCADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-564-7515
Mailing Address - Street 1:220 LIVINGSTON ST STE 108
Mailing Address - Street 2:
Mailing Address - City:NORTHVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07647-1739
Mailing Address - Country:US
Mailing Address - Phone:201-564-7515
Mailing Address - Fax:
Practice Address - Street 1:495 N 13TH ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-1317
Practice Address - Country:US
Practice Address - Phone:973-991-0220
Practice Address - Fax:973-990-0221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-04
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty