Provider Demographics
NPI:1770694788
Name:DYNAMIC PHYSICAL THERAPY OF JACKSONVILLE
Entity type:Organization
Organization Name:DYNAMIC PHYSICAL THERAPY OF JACKSONVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ONOFRE
Authorized Official - Middle Name:FERNAN
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-381-9207
Mailing Address - Street 1:1717 BLANDING BLVD
Mailing Address - Street 2:STE 104
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210
Mailing Address - Country:US
Mailing Address - Phone:904-381-9205
Mailing Address - Fax:904-381-9208
Practice Address - Street 1:1717 BLANDING BLVD
Practice Address - Street 2:STE 104
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210
Practice Address - Country:US
Practice Address - Phone:904-381-9205
Practice Address - Fax:904-381-9208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT10089225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY914MOtherBCBS
FLK7645Medicare ID - Type Unspecified