Basic Information
| Provider Information | |||||||||
| NPI: | 1346334570 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DYNAMIC PHYSICAL THERAPY & REHABILITATION CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1864 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296021864 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432921900 | ||||||||
| FaxNumber: | 8432921902 | ||||||||
| Practice Location | |||||||||
| Address1: | 123 S CASHUA DR | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295014001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432921900 | ||||||||
| FaxNumber: | 8432921902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 05/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | STO.DOMINGO | ||||||||
| AuthorizedOfficialFirstName: | MARVIN | ||||||||
| AuthorizedOfficialMiddleName: | SALAMANCA | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8432921900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2899 | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.