Healthcare Provider Details

I. General information

NPI: 1821462904
Provider Name (Legal Business Name): DYNAMIC INTEGRATIVE HEALTH PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2015
Last Update Date: 01/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1382 E ALLUVIAL AVE STE 106
FRESNO CA
93720-2699
US

IV. Provider business mailing address

1382 E ALLUVIAL AVE SUITE 106
FRESNO CA
93720-2699
US

V. Phone/Fax

Practice location:
  • Phone: 559-432-9700
  • Fax: 559-432-9701
Mailing address:
  • Phone: 559-432-9700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC32064
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC29486
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA32806
License Number StateCA

VIII. Authorized Official

Name: DR. CHRISTOPHER J LONG
Title or Position: BUSINESS PARTNER
Credential: D.C.
Phone: 559-432-9700