1487647004 NPI number — DYNAMIC PHYSICAL THERAPY INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487647004 NPI number — DYNAMIC PHYSICAL THERAPY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DYNAMIC PHYSICAL THERAPY 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:
1487647004
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
746 FAIRMONT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTOVER
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26501-4060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-225-5222
Provider Business Mailing Address Fax Number:
304-225-5224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3411 UNIVERSITY AVE STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORGANTOWN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26505-7240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-225-5222
Provider Business Practice Location Address Fax Number:
304-225-5224
Provider Enumeration Date:
08/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KINKADE
Authorized Official First Name:
LINCOLN
Authorized Official Middle Name:
NATHANIEL
Authorized Official Title or Position:
OWNER/PT
Authorized Official Telephone Number:
304-225-5222

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: 3810002407 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 09043124 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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