Healthcare Provider Details

I. General information

NPI: 1497090302
Provider Name (Legal Business Name): DYNAMIC PHYSIOTHERAPY SERVICES CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2012
Last Update Date: 01/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 W 103RD ST
OAK LAWN IL
60453-4718
US

IV. Provider business mailing address

601 S ADAMS ST
WESTMONT IL
60559-2206
US

V. Phone/Fax

Practice location:
  • Phone: 708-422-3422
  • Fax:
Mailing address:
  • Phone: 773-354-3063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: WITOLD MIERZWA
Title or Position: OWNER
Credential: LPT
Phone: 773-354-3063