Provider Demographics
NPI:1710036421
Name:DYNAMIC REHABILITATION, INC.
Entity Type:Organization
Organization Name:DYNAMIC REHABILITATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:E
Authorized Official - Last Name:DHOM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:630-406-1800
Mailing Address - Street 1:1180 W. WILSON ST, SUITE B
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510
Mailing Address - Country:US
Mailing Address - Phone:630-406-1800
Mailing Address - Fax:630-406-1805
Practice Address - Street 1:1180 W. WILSON ST, SUITE B
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510
Practice Address - Country:US
Practice Address - Phone:630-406-1800
Practice Address - Fax:630-406-1805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.008799225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04520794OtherBCBS
IL04520794OtherBCBS