Provider Demographics
NPI:1245543255
Name:DYNAMIC REHAB PT, PC
Entity type:Organization
Organization Name:DYNAMIC REHAB PT, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ANATOLI
Authorized Official - Middle Name:
Authorized Official - Last Name:YOSHOVAYEV
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:917-977-0096
Mailing Address - Street 1:8502 139TH ST APT 3E
Mailing Address - Street 2:
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435-2649
Mailing Address - Country:US
Mailing Address - Phone:917-977-0096
Mailing Address - Fax:
Practice Address - Street 1:316 N 6TH ST
Practice Address - Street 2:
Practice Address - City:PROSPECT PARK
Practice Address - State:NJ
Practice Address - Zip Code:07508-2122
Practice Address - Country:US
Practice Address - Phone:973-910-0307
Practice Address - Fax:718-233-2570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0292741225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty