Provider Demographics
NPI:1205472594
Name:DYER, LOGAN G (LAC)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:G
Last Name:DYER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 AMENDMENT AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-3156
Mailing Address - Country:US
Mailing Address - Phone:803-818-7762
Mailing Address - Fax:803-258-6503
Practice Address - Street 1:154 AMENDMENT AVE STE 103
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-3156
Practice Address - Country:US
Practice Address - Phone:803-818-7762
Practice Address - Fax:803-258-6503
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC331171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist