=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386114965
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DYNAMIC MEDICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2018
-----------------------------------------------------
Last Update Date | 04/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 935 3RD STREET
-----------------------------------------------------
City | VINTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24179-3302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-375-2631
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 935 3RD STREET
-----------------------------------------------------
City | VINTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24179-3302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-375-2631
-----------------------------------------------------
Fax | 540-375-2636
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATING OFFICER
-----------------------------------------------------
Name | MR. WILLIAM ANDERSON COLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 540-632-8460
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------