Provider Demographics
NPI:1437580008
Name:DYNAMIC NUTRITION AND WELLNESS, LLC
Entity Type:Organization
Organization Name:DYNAMIC NUTRITION AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-366-2490
Mailing Address - Street 1:1700 N DIXIE HWY
Mailing Address - Street 2:STE 129
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-1850
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 N DIXIE HWY
Practice Address - Street 2:STE 129
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-1850
Practice Address - Country:US
Practice Address - Phone:954-366-2490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND6066133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty