Provider Demographics
NPI:1598251704
Name:DYNAMIC PAIN & WELLNESS PLLC
Entity Type:Organization
Organization Name:DYNAMIC PAIN & WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-226-6801
Mailing Address - Street 1:930 MAR WALT DRIVE
Mailing Address - Street 2:
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:877-413-5104
Practice Address - Street 1:28490 2ND ST
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-7150
Practice Address - Country:US
Practice Address - Phone:850-266-6801
Practice Address - Fax:877-413-5104
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DYNAMIC PAIN & WELLNESS PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016064100Medicaid