MEDICARE: DIRTY SOUTH THERAPEUTICS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1740052414
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIRTY SOUTH THERAPEUTICS LLC

Provider Business Mailing Address
First Line	:	67 E WATER ST
Second Line	:
City	:	CHILLICOTHEE
State	:	OH
Zip	:	45601-2535
Country	:	US
Telephone Number	:	740-701-2890
Fax Number	:

Provider Business Practice Location Address
First Line	:	67 E WATER ST
Second Line	:
City	:	CHILLICOTHEE
State	:	OH
Zip	:	45601-2535
Country	:	US
Telephone Number	:	740-701-2890
Fax Number	:	740-879-2133

Authorized Official
Title or Position	:	OWNER
Name	:	DANIEL RAY MATHUEWS
Credential	:
Telephone Number	:	740-701-2890

Provider Enumeration Date	:	10/26/2023
Last Update Date	:	07/23/2024

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