Healthcare Provider Details

I. General information

NPI: 1538452982
Provider Name (Legal Business Name): DYNAMIC HEALTH AND PAIN MANAGEMENT, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2011
Last Update Date: 05/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4707 SOUTH BLVD
CHARLOTTE NC
28217-2117
US

IV. Provider business mailing address

4707 SOUTH BLVD
CHARLOTTE NC
28217-2117
US

V. Phone/Fax

Practice location:
  • Phone: 704-525-6288
  • Fax: 704-525-6384
Mailing address:
  • Phone: 704-525-6288
  • Fax: 704-525-6384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number222692
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number9900407
License Number StateNC

VIII. Authorized Official

Name: HEIDI COX
Title or Position: SECRETARY/TREASURER
Credential:
Phone: 704-525-6288