Basic Information
| Provider Information | |||||||||
| NPI: | 1295349413 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DYNAMIC PHYSICAL THERAPY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2855 INTERNATIONAL CIRCLE | ||||||||
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| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809103144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194478822 | ||||||||
| FaxNumber: | 7194478832 | ||||||||
| Practice Location | |||||||||
| Address1: | 5775 N UNION BLVD | ||||||||
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| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809181744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194347044 | ||||||||
| FaxNumber: | 7193751276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2020 | ||||||||
| LastUpdateDate: | 09/04/2020 | ||||||||
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| AuthorizedOfficialLastName: | YASSA | ||||||||
| AuthorizedOfficialFirstName: | EMAD | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7194478822 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | 09/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.