Basic Information
| Provider Information | |||||||||
| NPI: | 1316570310 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DYNAMIC REHABILITATION CONSULTANTS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 766 S MARTIN ST APT B332 | ||||||||
| Address2: | |||||||||
| City: | LONGMONT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805016449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166418808 | ||||||||
| FaxNumber: | 8186712225 | ||||||||
| Practice Location | |||||||||
| Address1: | 4401 UNION ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSTOWN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805342800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166418808 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2020 | ||||||||
| LastUpdateDate: | 03/25/2020 | ||||||||
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| AuthorizedOfficialLastName: | WITEK | ||||||||
| AuthorizedOfficialFirstName: | PHILIP | ||||||||
| AuthorizedOfficialMiddleName: | ALEXANDER | ||||||||
| AuthorizedOfficialTitleorPosition: | MD/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3166418808 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | DR.0061737 | 01 | CO | MEDICAL LICENSE | OTHER |