Provider Demographics
NPI:1942894316
Name:DYNAMIC PHYSICAL THERAPY & WELLNESS LLC
Entity Type:Organization
Organization Name:DYNAMIC PHYSICAL THERAPY & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:TANAKA
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:208-569-6599
Mailing Address - Street 1:352 E RIVERSIDE DR STE A6
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-6999
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:352 E RIVERSIDE DR STE A6
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-6999
Practice Address - Country:US
Practice Address - Phone:208-569-6599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty