1376637454 NPI number — DYNAMIC PHYSICAL THERAPY & REHABILITATION CENTER LLC

Table of content: (NPI 1376637454)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376637454 NPI number — DYNAMIC PHYSICAL THERAPY & REHABILITATION CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DYNAMIC PHYSICAL THERAPY & REHABILITATION 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:
1376637454
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1864
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29602-1864
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-331-0919
Provider Business Mailing Address Fax Number:
864-331-0922

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2307 E HIGHWAY 76
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29571-6351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-423-4888
Provider Business Practice Location Address Fax Number:
843-423-4849
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STO.DOMINGO
Authorized Official First Name:
MARVIN
Authorized Official Middle Name:
SALAMANCA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
843-910-4093

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2466 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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