Healthcare Provider Details

I. General information

NPI: 1407046881
Provider Name (Legal Business Name): ADVANCED DYNAMIC THERAPIES PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2007
Last Update Date: 09/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

644 E REGENT ST 101
INGLEWOOD CA
90301-1433
US

IV. Provider business mailing address

644 E REGENT ST 101
INGLEWOOD CA
90301-1433
US

V. Phone/Fax

Practice location:
  • Phone: 310-330-1177
  • Fax: 310-330-1188
Mailing address:
  • Phone: 310-330-1177
  • Fax: 310-330-1188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT16833
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number49951
License Number StateCA

VIII. Authorized Official

Name: MR. MATTHEW REDDICK PERRY
Title or Position: DIRECTOR
Credential: R.P.T.
Phone: 323-295-5836