Provider Demographics
NPI:1871058560
Name:DUMAS, TYRONE
Entity type:Individual
Prefix:
First Name:TYRONE
Middle Name:
Last Name:DUMAS
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 1:12060 BELLEFONTAINE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63138-1903
Mailing Address - Country:US
Mailing Address - Phone:314-764-2099
Mailing Address - Fax:314-764-2152
Practice Address - Street 1:12060 BELLEFONTAINE RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63138-1903
Practice Address - Country:US
Practice Address - Phone:314-764-2099
Practice Address - Fax:314-764-2152
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1563261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care