Provider Demographics
NPI:1972705465
Name:DYNAMIC REHAB CENTER
Entity type:Organization
Organization Name:DYNAMIC REHAB CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-688-3636
Mailing Address - Street 1:10512 NORTHCLIFFE BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34608-3766
Mailing Address - Country:US
Mailing Address - Phone:352-688-3636
Mailing Address - Fax:352-688-1333
Practice Address - Street 1:10512 NORTHCLIFFE BLVD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34608-3766
Practice Address - Country:US
Practice Address - Phone:352-688-3636
Practice Address - Fax:352-688-1333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA15331251T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686608Medicare ID - Type UnspecifiedMC NUMBER