Provider Demographics
NPI:1386871630
Name:DYNAMIC SPINE & SPORT REHABILITATION LLC
Entity type:Organization
Organization Name:DYNAMIC SPINE & SPORT REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:INDRIERI
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:702-685-1607
Mailing Address - Street 1:8951 W SAHARA AVE STE 190
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-5899
Mailing Address - Country:US
Mailing Address - Phone:702-685-1607
Mailing Address - Fax:702-685-1506
Practice Address - Street 1:8951 W SAHARA AVE
Practice Address - Street 2:SUITE 190
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-5898
Practice Address - Country:US
Practice Address - Phone:702-808-4943
Practice Address - Fax:702-968-8637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-14
Last Update Date:2024-09-04
Deactivation Date:2020-10-26
Deactivation Code:
Reactivation Date:2020-12-02
Provider Licenses
StateLicense IDTaxonomies
NV1815225100000X
225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical RehabilitationGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100510631Medicaid