1528483229 NPI number — DYNAMIC REHAB AND SPINE, LLC

Table of content: (NPI 1528483229)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528483229 NPI number — DYNAMIC REHAB AND SPINE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DYNAMIC REHAB AND SPINE, 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:
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:
1528483229
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2380 PLANK RD
Provider Second Line Business Mailing Address:
A
Provider Business Mailing Address City Name:
FREDERICKSUBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-373-1303
Provider Business Mailing Address Fax Number:
540-373-6061

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2380 PLANK RD
Provider Second Line Business Practice Location Address:
A
Provider Business Practice Location Address City Name:
FREDERICKSUBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-373-1303
Provider Business Practice Location Address Fax Number:
540-373-6061
Provider Enumeration Date:
03/04/2014

Additional Information

Authorized Official

Authorized Official Last Name:
ERLE
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
540-373-1303

Provider Taxonomy Codes

  • Taxonomy code: 111NS0005X , with the licence number:  0104556636 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: VV7411B612 . This is a "MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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