1295764116 NPI number — DYNAMIC PHYSICAL THERAPY & SPORT ENHANCEMENT, INC

Table of content: DAVID E. MOLONY L.AC. (NPI 1376507889)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295764116 NPI number — DYNAMIC PHYSICAL THERAPY & SPORT ENHANCEMENT, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DYNAMIC PHYSICAL THERAPY & SPORT ENHANCEMENT, INC
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:
6
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:
1295764116
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16010 NW 57TH AVE UNIT 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI LAKES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33014-6708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-556-0315
Provider Business Mailing Address Fax Number:
305-556-0317

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16010 NW 57TH AVE UNIT 110
Provider Second Line Business Practice Location Address:
SUITE 325
Provider Business Practice Location Address City Name:
MIAMI LAKES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33014-6708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-556-0315
Provider Business Practice Location Address Fax Number:
305-556-0317
Provider Enumeration Date:
07/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SIMBECK
Authorized Official First Name:
AMY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
305-556-0315

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT15097 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 891482600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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