=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629885868
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DYNAMIC TRAINING XPLOSION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2024
-----------------------------------------------------
Last Update Date | 12/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2119 SEVEN OAKS ST SE
-----------------------------------------------------
City | LACEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98503-3090
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-235-2739
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4570 AVERY LN SE STE C PMB 1108
-----------------------------------------------------
City | LACEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-685-7414
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DAVID LETT
-----------------------------------------------------
Credential | MA, MS, CPT, TSAC-F,
-----------------------------------------------------
Telephone | 360-685-7414
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------