Provider Demographics
NPI:1871842633
Name:DYNAMIC PHYSICAL THERAPY, PLLC
Entity Type:Organization
Organization Name:DYNAMIC PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:T
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:859-230-8801
Mailing Address - Street 1:PO BOX 481
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0481
Mailing Address - Country:US
Mailing Address - Phone:859-230-8801
Mailing Address - Fax:
Practice Address - Street 1:390 WOODS EDGE DR
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-8143
Practice Address - Country:US
Practice Address - Phone:859-230-8801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY002851225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty