Provider Demographics
NPI:1952301145
Name:DYNAMIC EVALUATION CENTER OF SOUTH TEXAS, LLC
Entity Type:Organization
Organization Name:DYNAMIC EVALUATION CENTER OF SOUTH TEXAS, LLC
Other - Org Name:DYNAMIC PERFORMANCE PHYSICAL THERAPY AND REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:H
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:NCMOA
Authorized Official - Phone:361-851-0209
Mailing Address - Street 1:5920 SARATOGA BLVD
Mailing Address - Street 2:SUITE 645
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414-4103
Mailing Address - Country:US
Mailing Address - Phone:361-851-0209
Mailing Address - Fax:361-851-0147
Practice Address - Street 1:5920 SARATOGA BLVD
Practice Address - Street 2:SUITE 645
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414-4103
Practice Address - Country:US
Practice Address - Phone:361-851-0209
Practice Address - Fax:361-851-0147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX225100000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX456790Medicare ID - Type Unspecified