Provider Demographics
NPI:1902267263
Name:DYNAMIC PHYSICAL THERAPY & SPORTS CLINIC
Entity Type:Organization
Organization Name:DYNAMIC PHYSICAL THERAPY & SPORTS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:201-472-8828
Mailing Address - Street 1:407 39TH ST STE 301
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-4817
Mailing Address - Country:US
Mailing Address - Phone:201-472-8828
Mailing Address - Fax:
Practice Address - Street 1:407 39TH ST STE 301
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-4817
Practice Address - Country:US
Practice Address - Phone:201-472-8828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01620600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1699143594OtherNPI NUMBER