Healthcare Provider Details

I. General information

NPI: 1386123560
Provider Name (Legal Business Name): DYNAMIC PAIN & WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 03/02/2020
Certification Date: 03/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4724 AIRPORT BLVD
MOBILE AL
36608-3134
US

IV. Provider business mailing address

930 MAR WALT DRIVE
FORT WALTON BEACH FL
32547
US

V. Phone/Fax

Practice location:
  • Phone: 850-226-6801
  • Fax: 877-413-5104
Mailing address:
  • Phone: 850-226-6801
  • Fax: 877-413-5104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SARAH BAILEY
Title or Position: CREDENTIALING
Credential:
Phone: 850-226-6801