Healthcare Provider Details

I. General information

NPI: 1952380099
Provider Name (Legal Business Name): DYNAMIC SPORT AND SPINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 12/24/2025
Certification Date: 12/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 SE OTIS CORLEY DR STE 11
BENTONVILLE AR
72712-3991
US

IV. Provider business mailing address

2701 SE OTIS CORLEY DR STE 11
BENTONVILLE AR
72712-3991
US

V. Phone/Fax

Practice location:
  • Phone: 479-235-2545
  • Fax: 479-235-2546
Mailing address:
  • Phone: 479-235-2545
  • Fax: 479-235-2546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number8295
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ERIN KRISTEN ROSSO
Title or Position: OWNER
Credential: DPT
Phone: 303-949-6453