Healthcare Provider Details

I. General information

NPI: 1013977354
Provider Name (Legal Business Name): CRAIG A DYER ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 N CLINTON ST
FT WAYNE IN
46825-5822
US

IV. Provider business mailing address

11328 RUPERT RD
HARLAN IN
46743-7429
US

V. Phone/Fax

Practice location:
  • Phone: 260-484-8551
  • Fax:
Mailing address:
  • Phone: 260-657-1449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000451A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: