1952873812 NPI number — DYNAMIC PHYSICAL THERAPY, INC.

Table of content: (NPI 1952873812)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952873812 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:
1952873812
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1110 SHAWNEE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIMA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45805-3529
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-221-6717
Provider Business Mailing Address Fax Number:
419-222-0507

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 S COUNTY FARM RD STE 310
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHEATON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60187-4547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-937-3030
Provider Business Practice Location Address Fax Number:
866-221-3400
Provider Enumeration Date:
12/17/2018

Additional Information

Authorized Official

Authorized Official Last Name:
ROUSH
Authorized Official First Name:
BRAD
Authorized Official Middle Name:
C
Authorized Official Title or Position:
EXECUTIVE VICE PRESIDENT
Authorized Official Telephone Number:
419-221-6710

Provider Taxonomy Codes

  • Taxonomy code: 261QR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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