Provider Demographics
NPI:1396420626
Name:DYNAMIC AT HOME
Entity type:Organization
Organization Name:DYNAMIC AT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:
Authorized Official - Last Name:CABALLERO
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:201-564-7515
Mailing Address - Street 1:32 HANSEN ST
Mailing Address - Street 2:
Mailing Address - City:TAPPAN
Mailing Address - State:NY
Mailing Address - Zip Code:10983-1717
Mailing Address - Country:US
Mailing Address - Phone:201-564-7515
Mailing Address - Fax:201-564-7514
Practice Address - Street 1:32 HANSEN ST
Practice Address - Street 2:
Practice Address - City:TAPPAN
Practice Address - State:NY
Practice Address - Zip Code:10983-1717
Practice Address - Country:US
Practice Address - Phone:201-564-7515
Practice Address - Fax:201-564-7514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation