Basic Information
| Provider Information | |||||||||
| NPI: | 1053534461 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DYE | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | ALBERT | ||||||||
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| Credential: | M.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1917 N LAKEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086648194 | ||||||||
| FaxNumber: | 2086671847 | ||||||||
| Practice Location | |||||||||
| Address1: | 1172 W HAYDEN AVE | ||||||||
| Address2: | |||||||||
| City: | HAYDEN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838358700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087738111 | ||||||||
| FaxNumber: | 2087738385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 06/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT2429 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT25530 | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT2429 | 01 | ID | BUREAU OF OCCUPATIONAL LICENSES | OTHER |