Provider Demographics
NPI:1306037155
Name:DYNAMIC CHIROPRACTIC, INC.
Entity Type:Organization
Organization Name:DYNAMIC CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:O'GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:954-938-4321
Mailing Address - Street 1:1730 E COMMERCIAL BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33334
Mailing Address - Country:US
Mailing Address - Phone:954-938-4321
Mailing Address - Fax:954-938-4322
Practice Address - Street 1:1730 E COMMERCIAL BOULEVARD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33334
Practice Address - Country:US
Practice Address - Phone:954-938-4321
Practice Address - Fax:954-938-4322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 8533261Q00000X
FLCH8533261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
493010Medicare UPIN
76960Medicare PIN