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General NPI Number Information
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NPI Number | 1083945554
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Entity Type | Organization
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Legal Business Name | DYNAMIC LIFE THERAPY AND WELLNESS PC
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Dates
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Enumeration Date | 01/23/2010
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Last Update Date | 06/03/2013
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Provider Practice Location Address
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Address Line | 3763 39TH AVE SUITE 100
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City | COLUMBUS
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State | NE
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Zip | 68601-4504
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Country | US
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Telephone | 402-606-4492
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Fax | 402-615-4168
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Provider Business Mailing Address
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Address Line | 3763 39TH AVE SUITE 100
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City | COLUMBUS
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State | NE
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Zip | 68601-4504
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Country | US
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Telephone | 402-606-4492
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Fax | 402-606-4168
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | SHAREE JO FEJFAR-JEDLICKA
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Credential | PT
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Telephone | 402-606-4492
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 1752
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License Number State | NE
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