Healthcare Provider Details

I. General information

NPI: 1053534461
Provider Name (Legal Business Name): JEREMY ALBERT DYE M.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1172 W HAYDEN AVE
HAYDEN ID
83835-8700
US

IV. Provider business mailing address

1917 N LAKEWOOD DR
COEUR D ALENE ID
83814-2634
US

V. Phone/Fax

Practice location:
  • Phone: 208-773-8111
  • Fax: 208-773-8385
Mailing address:
  • Phone: 208-664-8194
  • Fax: 208-667-1847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT2429
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT25530
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: