Healthcare Provider Details

I. General information

NPI: 1679197735
Provider Name (Legal Business Name): DYNAMIC PAIN & WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2020
Last Update Date: 06/04/2020
Certification Date: 06/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 JOHN KNOX RD BLDG 200
TALLAHASSEE FL
32303-4114
US

IV. Provider business mailing address

930 MAR WALT DR UNIT C
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 Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: JULIA CSEJKA
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 850-398-5031