Healthcare Provider Details

I. General information

NPI: 1790228658
Provider Name (Legal Business Name): DYNAMIC PAIN & WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2016
Last Update Date: 06/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CALUSA BLVD
DESTIN FL
32541-5753
US

IV. Provider business mailing address

200 CALUSA BLVD SUITE 100
DESTIN FL
32541-5753
US

V. Phone/Fax

Practice location:
  • Phone: 850-226-6801
  • Fax:
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: MATHEW MCCUNE
Title or Position: CEO
Credential: MD
Phone: 850-226-6801