Provider Demographics
NPI:1528483229
Name:DYNAMIC REHAB AND SPINE, LLC
Entity type:Organization
Organization Name:DYNAMIC REHAB AND SPINE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ERLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:540-373-1303
Mailing Address - Street 1:2380 PLANK RD
Mailing Address - Street 2:A
Mailing Address - City:FREDERICKSUBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401
Mailing Address - Country:US
Mailing Address - Phone:540-373-1303
Mailing Address - Fax:540-373-6061
Practice Address - Street 1:2380 PLANK RD
Practice Address - Street 2:A
Practice Address - City:FREDERICKSUBURG
Practice Address - State:VA
Practice Address - Zip Code:22401
Practice Address - Country:US
Practice Address - Phone:540-373-1303
Practice Address - Fax:540-373-6061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-04
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556636111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV7411B612OtherMEDICARE