=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982938817
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DYNAMIC PT AND REHAB LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2009
-----------------------------------------------------
Last Update Date | 09/24/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8136 OKEECHOBEE BLVD SUITE A & B
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33411-2002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 156-116-9633
-----------------------------------------------------
Fax | 156-161-6932
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8136 OKEECHOBEE BLVD SUITE A & B
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33411-2002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 156-116-9633
-----------------------------------------------------
Fax | 156-161-6932
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL PARTNER
-----------------------------------------------------
Name | MR. OLEG RUBIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 201-819-4348
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | HCC8564
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------