Provider Demographics
NPI:1285007989
Name:DYNAMIC PAIN & WELLNESS PLLC
Entity Type:Organization
Organization Name:DYNAMIC PAIN & WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MATHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCUNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-502-3310
Mailing Address - Street 1:930 MARWALT DRIVE
Mailing Address - Street 2:SUITE B AND C
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547
Mailing Address - Country:US
Mailing Address - Phone:850-226-6801
Mailing Address - Fax:
Practice Address - Street 1:930 MARWALT DRIVE
Practice Address - Street 2:SUITE B AND C
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547
Practice Address - Country:US
Practice Address - Phone:850-226-6801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-04
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME108551208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty