Provider Demographics
NPI:1508181272
Name:DYNAMIC HEALTH CENTERS
Entity Type:Organization
Organization Name:DYNAMIC HEALTH CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:DISTEFANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-262-5625
Mailing Address - Street 1:163 SW STONEGATE TER STE 109
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32024-3459
Mailing Address - Country:US
Mailing Address - Phone:386-438-8391
Mailing Address - Fax:
Practice Address - Street 1:163 SW STONEGATE TER STE 109
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32024-3459
Practice Address - Country:US
Practice Address - Phone:386-438-8391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-06
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC8936207Q00000X, 261QU0200X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006309100Medicaid
FLDQ721AMedicare PIN
FL103964Medicare Oscar/Certification