Provider Demographics
NPI:1063720035
Name:DYNAMIC HEALTH CHIROPRACTIC
Entity type:Organization
Organization Name:DYNAMIC HEALTH CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:
Authorized Official - Last Name:SUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:650-593-2888
Mailing Address - Street 1:540 RALSTON AVE STE D
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94002-2866
Mailing Address - Country:US
Mailing Address - Phone:650-593-2888
Mailing Address - Fax:650-593-2880
Practice Address - Street 1:540 RALSTON AVE STE D
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-2866
Practice Address - Country:US
Practice Address - Phone:650-593-2888
Practice Address - Fax:650-593-2880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-23
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26318111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0263180Medicaid
U79420Medicare UPIN
CADC0263180Medicaid