Healthcare Provider Details

I. General information

NPI: 1700398070
Provider Name (Legal Business Name): DYNAMIC PAIN AND WELLNESS PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 10/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 MAR WALT DRIVE
FORT WALTON BEACH FL
32547-6706
US

IV. Provider business mailing address

930 MAR WALT DRIVE
FORT WALTON BEACH FL
32547-6706
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 Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MATHEW MCCUNE
Title or Position: CEO
Credential: MD
Phone: 850-226-6801