Provider Demographics
NPI:1841332855
Name:DYER NURSING HOME, INC.
Entity type:Organization
Organization Name:DYER NURSING HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-692-4545
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:TN
Mailing Address - Zip Code:38330-0160
Mailing Address - Country:US
Mailing Address - Phone:731-692-4545
Mailing Address - Fax:731-692-4447
Practice Address - Street 1:1124 NORTH MAIN
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:TN
Practice Address - Zip Code:38330-0160
Practice Address - Country:US
Practice Address - Phone:731-692-4545
Practice Address - Fax:731-692-4447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN351314000000X, 313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7440580Medicaid
TN445468Medicare ID - Type Unspecified