Provider Demographics
NPI:1912966409
Name:ATHLETIC DYNAMICS LLC
Entity Type:Organization
Organization Name:ATHLETIC DYNAMICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:VANLEUVEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT CSCS
Authorized Official - Phone:518-641-6775
Mailing Address - Street 1:7 SOUTHWOODS BLVD, 4TH FL
Mailing Address - Street 2:ATHLETIC DYNAMICS LLC C/O CAPITOL CARDIOLOGY ASSOC
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12211-2526
Mailing Address - Country:US
Mailing Address - Phone:518-641-6775
Mailing Address - Fax:518-292-6085
Practice Address - Street 1:7 SOUTHWOODS BLVD
Practice Address - Street 2:4TH FL, ATHLETIC DYNAMICS LLC
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12211-2526
Practice Address - Country:US
Practice Address - Phone:518-641-6775
Practice Address - Fax:518-292-6085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-22
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02251054Medicaid
NYBA0874Medicare PIN