MEDICARE: DYNAMIC CARE OT, PT, SLP PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	252Y00000X	Early Intervention Provider Agency	021147	NY

General Provider Information

NPI Number	:	1194094839
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DYNAMIC CARE OT, PT, SLP PLLC

Provider Business Mailing Address
First Line	:	7540 AUSTIN ST
Second Line	:	3GR
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-6248
Country	:	US
Telephone Number	:	718-286-9212
Fax Number	:

Provider Business Practice Location Address
First Line	:	7540 AUSTIN ST
Second Line	:	3GR
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-6248
Country	:	US
Telephone Number	:	718-286-9212
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. JOSE DAVILA
Credential	:	PT,MPH
Telephone Number	:	718-286-9212

Provider Enumeration Date	:	12/27/2011
Last Update Date	:	05/11/2013

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