Provider Demographics
NPI:1821462904
Name:DYNAMIC INTEGRATIVE HEALTH PC
Entity Type:Organization
Organization Name:DYNAMIC INTEGRATIVE HEALTH PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:559-432-9700
Mailing Address - Street 1:1382 E ALLUVIAL AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2699
Mailing Address - Country:US
Mailing Address - Phone:559-432-9700
Mailing Address - Fax:
Practice Address - Street 1:1382 E ALLUVIAL AVE STE 106
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2699
Practice Address - Country:US
Practice Address - Phone:559-432-9700
Practice Address - Fax:559-432-9701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-30
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC32064111N00000X
DC29486111N00000X
CAA32806208D00000X
363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty