Provider Demographics
NPI:1053884379
Name:DYNAMIC PHYSICAL THERAPY AND SPORTS REHAB
Entity type:Organization
Organization Name:DYNAMIC PHYSICAL THERAPY AND SPORTS REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KINCHIN
Authorized Official - Middle Name:
Authorized Official - Last Name:NONOG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-884-5987
Mailing Address - Street 1:5049 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034-1131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5049 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-1131
Practice Address - Country:US
Practice Address - Phone:213-884-5987
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-09
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPENDINGMedicaid