1245881457 NPI number — DYNAMISM PHYSICAL THERAPY, P.C.

Table of content: (NPI 1245881457)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245881457 NPI number — DYNAMISM PHYSICAL THERAPY, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DYNAMISM PHYSICAL THERAPY, P.C.
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:
1245881457
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
245 WOODFIELD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST HEMPSTEAD
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11552-2528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-922-5762
Provider Business Mailing Address Fax Number:
515-565-0929

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15280 ROCKAWAY BLVD STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JAMAICA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11434-2800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-464-1023
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/28/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BORJA
Authorized Official First Name:
NINO POMPEYO ROCO
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
908-922-5762

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 06050059 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".