Provider Demographics
NPI:1053719484
Name:DYNAMIC PHYSICAL THERAPY OF NEW JERSEY P.A.
Entity type:Organization
Organization Name:DYNAMIC PHYSICAL THERAPY OF NEW JERSEY P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BAUTISTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-309-9564
Mailing Address - Street 1:6248 80TH ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLE VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11379-1323
Mailing Address - Country:US
Mailing Address - Phone:718-429-2888
Mailing Address - Fax:646-304-8252
Practice Address - Street 1:20 THOREAU DR
Practice Address - Street 2:POETS SQUARE
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-4329
Practice Address - Country:US
Practice Address - Phone:732-303-1425
Practice Address - Fax:732-780-7990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-17
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01291900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty