1780888180 NPI number — DYNAMIC THERAPY CENTER, LLC

Table of content: (NPI 1780888180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780888180 NPI number — DYNAMIC THERAPY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DYNAMIC THERAPY CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780888180
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6650 EASTGATE BLVD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37090-6017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6650 EASTGATE BLVD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37090-6017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-443-4445
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/12/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KURTH
Authorized Official First Name:
KARYN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
615-443-4445

Provider Taxonomy Codes

  • Taxonomy code: 224Z00000X , with the licence number:  66 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 224Z00000X , with the licence number: 1601 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 225100000X , with the licence number: 1423 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 225X00000X , with the licence number: 1692 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 235Z00000X , with the licence number: 2691 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 235Z00000X , with the licence number: 3453 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5441186 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".