Provider Demographics
NPI:1801401955
Name:MYRICK, DEXTER T
Entity Type:Individual
Prefix:
First Name:DEXTER
Middle Name:T
Last Name:MYRICK
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 1:158 HOPEWELL CHURCH RD NW
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-9743
Mailing Address - Country:US
Mailing Address - Phone:478-233-4527
Mailing Address - Fax:
Practice Address - Street 1:158 HOPEWELL CHURCH RD NW
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-9743
Practice Address - Country:US
Practice Address - Phone:478-233-4527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA05Medicaid