Healthcare Provider Details

I. General information

NPI: 1164564688
Provider Name (Legal Business Name): DYNAMICS WALKAGAIN REHAB INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 02/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 W OLYMPIC BLVD STE 130
LOS ANGELES CA
90006-3734
US

IV. Provider business mailing address

1830 W OLYMPIC BLVD STE 123
LOS ANGELES CA
90006-3734
US

V. Phone/Fax

Practice location:
  • Phone: 213-383-6860
  • Fax: 213-383-6421
Mailing address:
  • Phone: 213-383-6860
  • Fax: 213-383-6421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberGPT000880
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. PETER SEAN
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: CPO
Phone: 213-383-6860