Provider Demographics
NPI:1760757272
Name:DYNAMIC HEALTH & ORTHOTICS
Entity Type:Organization
Organization Name:DYNAMIC HEALTH & ORTHOTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DEREK
Authorized Official - Last Name:HOLLINGSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-760-8803
Mailing Address - Street 1:3859 TEAYS VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-9622
Mailing Address - Country:US
Mailing Address - Phone:304-760-8803
Mailing Address - Fax:304-760-8825
Practice Address - Street 1:3859 TEAYS VALLEY RD
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9622
Practice Address - Country:US
Practice Address - Phone:304-760-8803
Practice Address - Fax:304-760-8825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVPLLC-124OtherSTATE OF WEST VIRGINIA-BOARD OF OSTEOPATHY