Provider Demographics
NPI:1083945554
Name:DYNAMIC LIFE THERAPY AND WELLNESS PC
Entity Type:Organization
Organization Name:DYNAMIC LIFE THERAPY AND WELLNESS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAREE
Authorized Official - Middle Name:JO
Authorized Official - Last Name:FEJFAR-JEDLICKA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:402-606-4492
Mailing Address - Street 1:3763 39TH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLUMBUS
Mailing Address - State:NE
Mailing Address - Zip Code:68601-4504
Mailing Address - Country:US
Mailing Address - Phone:402-606-4492
Mailing Address - Fax:402-606-4168
Practice Address - Street 1:3763 39TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:COLUMBUS
Practice Address - State:NE
Practice Address - Zip Code:68601-4504
Practice Address - Country:US
Practice Address - Phone:402-606-4492
Practice Address - Fax:402-615-4168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-23
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1752261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025818800Medicaid