Provider Demographics
NPI:1386770659
Name:DYNAMIC PHYSICAL THERAPY CENTER
Entity type:Organization
Organization Name:DYNAMIC PHYSICAL THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:DAVIS
Authorized Official - Last Name:A
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:908-620-1991
Mailing Address - Street 1:313 E WESTFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:ROSELLE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07204-2317
Mailing Address - Country:US
Mailing Address - Phone:908-620-1991
Mailing Address - Fax:908-620-9777
Practice Address - Street 1:313 E WESTFIELD AVE
Practice Address - Street 2:
Practice Address - City:ROSELLE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07204-2317
Practice Address - Country:US
Practice Address - Phone:908-620-1991
Practice Address - Fax:908-620-9777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ092206Medicare ID - Type Unspecified