Basic Information
| Provider Information | |||||||||
| NPI: | 1326294349 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DYNAMIC PHYSICAL THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 440 E ROOSEVELT RD | ||||||||
| Address2: | UNIT 104 | ||||||||
| City: | WEST CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601853902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308769186 | ||||||||
| FaxNumber: | 6308769187 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 N CASS AVE | ||||||||
| Address2: | |||||||||
| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605591601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306159170 | ||||||||
| FaxNumber: | 6304930995 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2008 | ||||||||
| LastUpdateDate: | 08/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | POWERS | ||||||||
| AuthorizedOfficialFirstName: | ROBIN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6308769186 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DYNAMIC PHYSICAL THERAPY MANAGEMENT SERVICES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070.008757 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.