Provider Demographics
NPI:1629885868
Name:DYNAMIC TRAINING XPLOSION LLC
Entity type:Organization
Organization Name:DYNAMIC TRAINING XPLOSION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LETT
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MS, CPT, TSAC-F,
Authorized Official - Phone:360-685-7414
Mailing Address - Street 1:4570 AVERY LN SE STE C PMB 1108
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503
Mailing Address - Country:US
Mailing Address - Phone:360-685-7414
Mailing Address - Fax:
Practice Address - Street 1:2119 SEVEN OAKS ST SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-3090
Practice Address - Country:US
Practice Address - Phone:714-235-2739
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-11
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty