Healthcare Provider Details

I. General information

NPI: 1952873812
Provider Name (Legal Business Name): DYNAMIC PHYSICAL THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 05/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S COUNTY FARM RD STE 310
WHEATON IL
60187-4547
US

IV. Provider business mailing address

1110 SHAWNEE RD
LIMA OH
45805-3529
US

V. Phone/Fax

Practice location:
  • Phone: 630-937-3030
  • Fax: 866-221-3400
Mailing address:
  • Phone: 419-221-6717
  • Fax: 419-222-0507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. BRAD C ROUSH
Title or Position: EXECUTIVE VICE PRESIDENT
Credential:
Phone: 419-221-6710