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General NPI Number Information
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NPI Number | 1750512364
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Entity Type | Individual
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Provider Name | JEREMY WILSON DYAR
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Gender | Male
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Dates
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Enumeration Date | 07/30/2009
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Last Update Date | 07/31/2009
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Provider Practice Location Address
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Address Line | 150 E 2ND AVE
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City | WILLIAMSON
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State | WV
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Zip | 25661-3602
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Country | US
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Telephone | 304-236-4247
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Fax |
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Provider Business Mailing Address
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Address Line | RR 3 BOX 609
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City | DELBARTON
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State | WV
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Zip | 25670-9799
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Country | US
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Telephone | 304-475-2312
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 2009-2532
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License Number State | WV
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