Provider Demographics
NPI:1942645502
Name:DYNAMIC HEALTH AND WELLNESS INC A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:DYNAMIC HEALTH AND WELLNESS INC A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:BROWN
Authorized Official - Last Name:RANDHAWA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-680-8306
Mailing Address - Street 1:441 COLUSA AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95991-4143
Mailing Address - Country:US
Mailing Address - Phone:530-329-8462
Mailing Address - Fax:530-329-8545
Practice Address - Street 1:441 COLUSA AVE
Practice Address - Street 2:SUITE B
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-4143
Practice Address - Country:US
Practice Address - Phone:530-329-8462
Practice Address - Fax:530-329-8545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-08
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG31686207P00000X
CAA99906207R00000X
CAG87823208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU442ZMedicare UPIN
CAA44839Medicare UPIN