Provider Demographics
NPI:1043807084
Name:THACKER, DEWEY
Entity Type:Individual
Prefix:
First Name:DEWEY
Middle Name:
Last Name:THACKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60615 BOLAR RD
Mailing Address - Street 2:
Mailing Address - City:MC ARTHUR
Mailing Address - State:OH
Mailing Address - Zip Code:45651-8640
Mailing Address - Country:US
Mailing Address - Phone:740-541-0912
Mailing Address - Fax:
Practice Address - Street 1:60615 BOLAR RD
Practice Address - Street 2:
Practice Address - City:MC ARTHUR
Practice Address - State:OH
Practice Address - Zip Code:45651-8640
Practice Address - Country:US
Practice Address - Phone:740-541-0912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide