Provider Demographics
NPI:1598709784
Name:SPINAL DYNAMICS OF WISCONSIN, SC
Entity Type:Organization
Organization Name:SPINAL DYNAMICS OF WISCONSIN, SC
Other - Org Name:BODY DYNAMICS OF WISCONSIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MARTI
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:414-302-0770
Mailing Address - Street 1:3333 N MAYFAIR RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-3219
Mailing Address - Country:US
Mailing Address - Phone:414-302-0770
Mailing Address - Fax:414-302-0775
Practice Address - Street 1:3333 N MAYFAIR RD
Practice Address - Street 2:SUITE 101
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-3219
Practice Address - Country:US
Practice Address - Phone:414-302-0770
Practice Address - Fax:414-302-0775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI81025Medicare ID - Type Unspecified