Basic Information
| Provider Information | |||||||||
| NPI: | 1316471667 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DYNAMIC PAIN RELIEF | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 PINNACLE DRIVE | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | PAPILLION | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4029328384 | ||||||||
| FaxNumber: | 4029328863 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 PINNACLE DRIVE | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | PAPILLION | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4029328384 | ||||||||
| FaxNumber: | 4029328863 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2017 | ||||||||
| LastUpdateDate: | 04/13/2017 | ||||||||
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| AuthorizedOfficialLastName: | BOECKENHAUER | ||||||||
| AuthorizedOfficialFirstName: | TONYA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIROPRACTOR | ||||||||
| AuthorizedOfficialTelephone: | 4022187989 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.C. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
No ID Information.