Provider Demographics
NPI:1710633144
Name:DYNAMIC PRIMARY HEALTHCARE CLINIC
Entity Type:Organization
Organization Name:DYNAMIC PRIMARY HEALTHCARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DISTEFANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-317-3214
Mailing Address - Street 1:924 SE LANTANA LOOP
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-6848
Mailing Address - Country:US
Mailing Address - Phone:330-323-8976
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:330-323-8976
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-24
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty