Provider Demographics
NPI:1295156792
Name:DYNAMIC PHYSICAL THERAPY ORTHOPEDIC SPINE AND SPORTS, PLLC
Entity type:Organization
Organization Name:DYNAMIC PHYSICAL THERAPY ORTHOPEDIC SPINE AND SPORTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:NOYOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-643-7259
Mailing Address - Street 1:203 E COLLEGE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:DEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:78016-2919
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:203 E COLLEGE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:DEVINE
Practice Address - State:TX
Practice Address - Zip Code:78016-2919
Practice Address - Country:US
Practice Address - Phone:830-663-5397
Practice Address - Fax:830-663-5359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-31
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1193323225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty