Provider Demographics
NPI:1013331479
Name:DYNAMIC EDGE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:DYNAMIC EDGE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:541-938-5553
Mailing Address - Street 1:113 S MAIN ST
Mailing Address - Street 2:113 S. MAIN
Mailing Address - City:MILTON FREEWATER
Mailing Address - State:OR
Mailing Address - Zip Code:97862-1342
Mailing Address - Country:US
Mailing Address - Phone:541-938-5553
Mailing Address - Fax:541-938-5554
Practice Address - Street 1:113 S MAIN ST
Practice Address - Street 2:113 S. MAIN
Practice Address - City:MILTON FREEWATER
Practice Address - State:OR
Practice Address - Zip Code:97862-1342
Practice Address - Country:US
Practice Address - Phone:541-938-5553
Practice Address - Fax:541-938-5554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3061261QP2000X
WAPT00006939261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR133980OtherMEDICARE UNSPECIFIED