Provider Demographics
NPI:1639446974
Name:DYNAMIC HEALTH CLINIC, LLC
Entity Type:Organization
Organization Name:DYNAMIC HEALTH CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:BICKLE
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:612-710-7415
Mailing Address - Street 1:6121 EXCELSIOR BLVD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SAINT LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2725
Mailing Address - Country:US
Mailing Address - Phone:612-710-7415
Mailing Address - Fax:
Practice Address - Street 1:6121 EXCELSIOR BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2725
Practice Address - Country:US
Practice Address - Phone:612-710-7415
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1517171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty