Provider Demographics
NPI:1386943322
Name:DYNAMIC CARE REHAB
Entity type:Organization
Organization Name:DYNAMIC CARE REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK JEROME
Authorized Official - Middle Name:VIRAY
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:915-408-0699
Mailing Address - Street 1:6006 N MESA ST STE 901
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-4655
Mailing Address - Country:US
Mailing Address - Phone:915-408-0699
Mailing Address - Fax:915-503-2297
Practice Address - Street 1:6006 N MESA ST STE 901
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-4655
Practice Address - Country:US
Practice Address - Phone:915-408-0699
Practice Address - Fax:915-503-2297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111483261Q00000X
TX1123313261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX669570000OtherTHE EXECUTIVE COUNCIL OF PHYSICAL THERAPY AND OCCUPATIONAL THERAPY EXAMINERS