Dynamic Primary Healthcare Clinic

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

Legal business name

DYNAMIC PRIMARY HEALTHCARE CLINIC

Practice address

163 SW Stonegate Ter Ste 109
Lake City, FL 32024-3459

Phone

(330) 323-8976

NPI assigned

Feb 24, 2022

Last updated

Mar 18, 2024By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

John Distefano

Title

Business Manager

Phone

(352) 317-3214

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in FL2 enrollments

Enrollment records 2

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1710633144. Details of each certification follow.

• CCN 103964 Rural health clinic · Active · Details

Rural health clinic certification: CCN 103964

Legal name

DYNAMIC PRIMARY HEALTHCARE CLINIC

Certification status

Active

Provider type (POS)

Rural health clinic

Participating since

May 17, 2012

Last certification

Feb 25, 2025

Ownership / control type

For profit – corporation

Organization structure

CorporationProprietary

Incorporated

Feb 11, 2022 in FL

Enrollment address

163 SW Stonegate Ter
Ste 109
Lake City, FL 32024-3459

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

All disclosed owners & managing parties 3

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

• Catherine Rose Brown, NURSE PRACTITIONER

  • Family Nurse Practitioner
  • Lake City, FL
  • NPI 1417239914

  5% Or Greater Direct Ownership Interest, W-2 Managing Employee

  CMS ownership
• Wilbert Clifton Jacobs II, M.D.

  • Family Medicine Physician
  • Lecanto, FL
  • NPI 1124348438

  Corporate Director

  CMS ownership

Change-of-ownership history 1

Change of ownership 1

Medicare changes of ownership in which this facility was the buyer or the seller.

• Dynamic Health Centers

  • Rural Health Clinic/Center
  • Lake City, FL
  • NPI 1508181272

  Acquired from, 2022-06-01

  CMS change of ownership

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Catherine Rose Brown, NURSE PRACTITIONER

  • Family Nurse Practitioner
  • Lake City, FL
  • NPI 1417239914
  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1645660800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1710720000000",
    "number": "1710633144",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "924 SE LANTANA LOOP",
            "city": "LAKE CITY",
            "state": "FL",
            "postal_code": "320256848",
            "telephone_number": "330-323-8976"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "163 SW STONEGATE TER STE 109",
            "city": "LAKE CITY",
            "state": "FL",
            "postal_code": "320243459",
            "telephone_number": "330-323-8976"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DYNAMIC PRIMARY HEALTHCARE CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-02-24",
        "last_updated": "2024-03-18",
        "certification_date": "2024-03-18",
        "status": "A",
        "authorized_official_last_name": "DISTEFANO",
        "authorized_official_first_name": "JOHN",
        "authorized_official_title_or_position": "BUSINESS MANAGER",
        "authorized_official_telephone_number": "352-317-3214"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Mitchell Duterte, MD
• Lauren Dutton
• Anna J Dyal
• Gregory A Dyle, PHARM D
• Dynamic Health Centers
• Earnest Emergency Physicians, LLC
• Miranda Leann Eash, APRN
• Easy to Breathe LLC
• Patricia J. Eaton
• Cassie Ebert, FNP-BC

• Family Medicine Physician in Lake City, FL
• Providers in Lake City, FL by specialty
• Family Medicine Physician in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 18, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.