# DYNAMIC PRIMARY HEALTHCARE CLINIC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1710633144
- **Authorized official:** JOHN DISTEFANO (BUSINESS MANAGER)
- **Authorized official phone:** (352) 317-3214

## Contact information

- **Practice address:** 163 SW STONEGATE TER STE 109, LAKE CITY, FL 32024-3459
- **Practice address phone:** (330) 323-8976
- **Mailing address:** 924 SE LANTANA LOOP, LAKE CITY, FL 32025-6848
- **Mailing address phone:** (330) 323-8976

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 02/24/2022
- **Last updated:** 03/18/2024