Provider Demographics
NPI:1669559944
Name:DYNAMIC PERFORMANCE THERAPY AND REHABILITATION, INC
Entity type:Organization
Organization Name:DYNAMIC PERFORMANCE THERAPY AND REHABILITATION, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:SAMUEL
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:256-837-5425
Mailing Address - Street 1:147 CASTLE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-8257
Mailing Address - Country:US
Mailing Address - Phone:256-837-5425
Mailing Address - Fax:256-837-2139
Practice Address - Street 1:147 CASTLE DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-8257
Practice Address - Country:US
Practice Address - Phone:256-837-5425
Practice Address - Fax:256-837-2139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51518990OtherBLUE CROSS BLUE SHIELD
ALJ624OtherMEDICARE PTAN