1811065071 NPI number — DYNAMIC REHABILITATION SERVICES

Table of content: (NPI 1811065071)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811065071 NPI number — DYNAMIC REHABILITATION SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DYNAMIC REHABILITATION SERVICES
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:
1811065071
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2102 E EVANS AVE
Provider Second Line Business Mailing Address:
#115
Provider Business Mailing Address City Name:
VALPARAISO
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46383-4096
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-476-0377
Provider Business Mailing Address Fax Number:
219-476-0388

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2102 E EVANS AVE
Provider Second Line Business Practice Location Address:
#115
Provider Business Practice Location Address City Name:
VALPARAISO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46383-4096
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-476-0377
Provider Business Practice Location Address Fax Number:
219-476-0388
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PHADKE
Authorized Official First Name:
SATISH
Authorized Official Middle Name:
DOLLY
Authorized Official Title or Position:
CO OWNER
Authorized Official Telephone Number:
219-476-0377

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: CG7971 . This is a "PALMETTO RR MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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