=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477242840
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DYNAMIC LIFE AND HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2023
-----------------------------------------------------
Last Update Date | 05/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 190 BROADWAY ST STE 101
-----------------------------------------------------
City | ASHEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28801-2501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-713-7440
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 74 MOODY AVE
-----------------------------------------------------
City | CANDLER
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28715-9606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-713-7440
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LPT
-----------------------------------------------------
Name | SAMUEL T EDWARDS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 828-713-7440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------