Healthcare Provider Details

I. General information

NPI: 1760691414
Provider Name (Legal Business Name): ERIC J. DYBVIG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 1ST ST NW
MOUNT VERNON IA
52314-1006
US

IV. Provider business mailing address

1315 14TH ST
MARION IA
52302-2565
US

V. Phone/Fax

Practice location:
  • Phone: 319-558-4009
  • Fax:
Mailing address:
  • Phone: 319-895-4009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number00523
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: