Provider Demographics
NPI:1649556630
Name:DYNAMIC SPINE & JOINT CENTER
Entity Type:Organization
Organization Name:DYNAMIC SPINE & JOINT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIERKING
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-253-0761
Mailing Address - Street 1:1100 SE CENTURY DR
Mailing Address - Street 2:STE D
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64081-3284
Mailing Address - Country:US
Mailing Address - Phone:816-655-2162
Mailing Address - Fax:
Practice Address - Street 1:1100 SE CENTURY DR
Practice Address - Street 2:STE D
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64081-3284
Practice Address - Country:US
Practice Address - Phone:816-655-2162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-23
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011000036111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty