1306039334 NPI number — DYNAMIC THERAPY CONCEPTS PLLC

Table of content: (NPI 1306039334)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306039334 NPI number — DYNAMIC THERAPY CONCEPTS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DYNAMIC THERAPY CONCEPTS PLLC
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:
1306039334
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
245 JENNIFER LYNN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PADUCAH
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42001-4861
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-705-5898
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
245 JENNIFER LYNN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PADUCAH
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42001-4861
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-705-5898
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HALL
Authorized Official First Name:
MARY
Authorized Official Middle Name:
LISA
Authorized Official Title or Position:
DOCTOR OF PHYSICAL THERAPY
Authorized Official Telephone Number:
270-705-5898

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  002256 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00454 . This is a "MEDICARE GROUP" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: P00435045 . This is a "MEDICARE RR - PTAN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1033121868 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 11856022 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: DG4266 . This is a "MEDICARE RR - GROUP" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100057690 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000551156 . This is a "ANTHEM BC & BS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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