Healthcare Provider Details

I. General information

NPI: 1861788986
Provider Name (Legal Business Name): DYNAMIC 1 MEDICAL AND REHAB CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 10/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 MARTIN LUTHER KING JR DRIVE SUITE B
ATLANTA GA
30310
US

IV. Provider business mailing address

2015 MARTIN LUTHER KING JR DRIVE SUITE B
ATLANTA GA
30310
US

V. Phone/Fax

Practice location:
  • Phone: 678-705-1733
  • Fax: 404-254-0529
Mailing address:
  • Phone: 678-705-1733
  • Fax: 404-254-0529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number026238
License Number StateGA

VIII. Authorized Official

Name: MR. DALE ADRIAN CAREY
Title or Position: CO OWNER
Credential:
Phone: 678-705-1733