Provider Demographics
NPI:1699179341
Name:DYNUTRIX, LLC
Entity Type:Organization
Organization Name:DYNUTRIX, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:P
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:ŇD
Authorized Official - Phone:203-962-2995
Mailing Address - Street 1:19 SILK ST
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06850-2916
Mailing Address - Country:US
Mailing Address - Phone:203-962-2995
Mailing Address - Fax:877-363-2230
Practice Address - Street 1:19 SILK ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-2916
Practice Address - Country:US
Practice Address - Phone:203-962-2995
Practice Address - Fax:877-363-2230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND00001 FEDERAL LIC174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty