Provider Demographics
NPI:1679535736
Name:WYATT & DAD, INC.
Entity Type:Organization
Organization Name:WYATT & DAD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:S
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-765-4392
Mailing Address - Street 1:3911 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-2914
Mailing Address - Country:US
Mailing Address - Phone:336-765-4392
Mailing Address - Fax:336-765-8555
Practice Address - Street 1:3911 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-2914
Practice Address - Country:US
Practice Address - Phone:336-765-4392
Practice Address - Fax:336-765-8555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7704216Medicaid
1318680001Medicare ID - Type Unspecified