Provider Demographics
NPI:1902983802
Name:DYNAMIC PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:DYNAMIC PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:REITZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:414-529-4605
Mailing Address - Street 1:10731 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130-2555
Mailing Address - Country:US
Mailing Address - Phone:414-529-4605
Mailing Address - Fax:
Practice Address - Street 1:10731 W FOREST HOME AVE
Practice Address - Street 2:
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130-2555
Practice Address - Country:US
Practice Address - Phone:414-529-4605
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3307-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty