Provider Demographics
NPI:1982823621
Name:DYNAMIC MEDICAL REHABILITATION CENTER OF DELRAY BEACH
Entity Type:Organization
Organization Name:DYNAMIC MEDICAL REHABILITATION CENTER OF DELRAY BEACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BASTKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-421-2005
Mailing Address - Street 1:660 LINTON BLVD
Mailing Address - Street 2:SUITE# 104
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33444-8167
Mailing Address - Country:US
Mailing Address - Phone:561-272-9113
Mailing Address - Fax:561-272-4115
Practice Address - Street 1:660 LINTON BLVD
Practice Address - Street 2:SUITE# 104
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33444-8167
Practice Address - Country:US
Practice Address - Phone:561-272-9113
Practice Address - Fax:561-272-4115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7166111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL77325OtherBCBS
FL55528Medicare ID - Type Unspecified