Provider Demographics
NPI:1952380099
Name:DYNAMIC SPORT AND SPINE
Entity Type:Organization
Organization Name:DYNAMIC SPORT AND SPINE
Other - Org Name:FOREVER FIT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:K
Authorized Official - Last Name:ROSSO
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, ATC
Authorized Official - Phone:303-949-6453
Mailing Address - Street 1:2806 SAINT MARYS RD
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-4559
Mailing Address - Country:US
Mailing Address - Phone:303-949-6453
Mailing Address - Fax:
Practice Address - Street 1:2806 SAINT MARYS RD
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-4559
Practice Address - Country:US
Practice Address - Phone:303-949-6453
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-16
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8295261QP2000X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO71789715Medicaid
CO71789715Medicaid