Provider Demographics
NPI:1780846154
Name:DYNAMIC PHYSICAL THERAPY ASSOC.PLLC
Entity Type:Organization
Organization Name:DYNAMIC PHYSICAL THERAPY ASSOC.PLLC
Other - Org Name:DBA DYNAMIC SPORTS PHYSICAL THERAPY & REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING/BILLER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-470-9515
Mailing Address - Street 1:164 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2955
Mailing Address - Country:US
Mailing Address - Phone:631-470-9515
Mailing Address - Fax:631-470-9513
Practice Address - Street 1:164 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2955
Practice Address - Country:US
Practice Address - Phone:631-470-9515
Practice Address - Fax:631-470-9513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-27
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty