Provider Demographics
NPI:1023440328
Name:DYER, JIMMY NEWT (MT009204)
Entity type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:NEWT
Last Name:DYER
Suffix:
Gender:M
Credentials:MT009204
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 N THORNTON AVE
Mailing Address - Street 2:214
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-8517
Mailing Address - Country:US
Mailing Address - Phone:706-275-0543
Mailing Address - Fax:
Practice Address - Street 1:1510 N THORNTON AVE
Practice Address - Street 2:214
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-8517
Practice Address - Country:US
Practice Address - Phone:706-275-0543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-08
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT009204225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist