Healthcare Provider Details

I. General information

NPI: 1174294508
Provider Name (Legal Business Name): MR. JAMES EDWARD DYSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JIM EDWARD DYSON LMT LICENSED MASSAGE

II. Dates (important events)

Enumeration Date: 09/24/2021
Last Update Date: 09/24/2021
Certification Date: 09/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 RESOURCE PKWY
WINDER GA
30680-8364
US

IV. Provider business mailing address

790 QUAILWOOD DR
ATHENS GA
30606-1450
US

V. Phone/Fax

Practice location:
  • Phone: 706-338-2178
  • Fax:
Mailing address:
  • Phone: 706-338-2178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT000841
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: