Provider Demographics
NPI:1750512364
Name:DYAR, JEREMY WILSON
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:WILSON
Last Name:DYAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JEREMY
Other - Middle Name:WILSON
Other - Last Name:DYAR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:RR 3 BOX 609
Mailing Address - Street 2:
Mailing Address - City:DELBARTON
Mailing Address - State:WV
Mailing Address - Zip Code:25670-9799
Mailing Address - Country:US
Mailing Address - Phone:304-475-2312
Mailing Address - Fax:
Practice Address - Street 1:150 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3602
Practice Address - Country:US
Practice Address - Phone:304-236-4247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-30
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2009-2532225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist