Provider Demographics
NPI:1932595691
Name:DYNAMIC PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:DYNAMIC PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:S
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:801-450-1881
Mailing Address - Street 1:1265 E FORT UNION BLVD
Mailing Address - Street 2:STE 110
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84047-1808
Mailing Address - Country:US
Mailing Address - Phone:801-849-0198
Mailing Address - Fax:
Practice Address - Street 1:1265 E FORT UNION BLVD STE 110
Practice Address - Street 2:
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84047-1807
Practice Address - Country:US
Practice Address - Phone:801-450-1881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-09
Last Update Date:2015-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9321575-0160261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy