Healthcare Provider Details

I. General information

NPI: 1093396160
Provider Name (Legal Business Name): DYNAMIC HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 W 21ST ST
CLOVIS NM
88101-4154
US

IV. Provider business mailing address

912 W 21ST ST
CLOVIS NM
88101-4154
US

V. Phone/Fax

Practice location:
  • Phone: 575-935-9000
  • Fax: 575-935-1002
Mailing address:
  • Phone: 575-935-9000
  • Fax: 575-935-1002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LACEY MEEKS
Title or Position: NP/OWNER
Credential:
Phone: 806-481-7000