1174537880 NPI number — LOLA M. DIXON APN

Table of content: LOLA M. DIXON APN (NPI 1174537880)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174537880 NPI number — LOLA M. DIXON APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIXON
Provider First Name:
LOLA
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174537880
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6939 97TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO RIDGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60415-1187
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-233-9883
Provider Business Mailing Address Fax Number:
708-202-7960

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5TH AVE
Provider Second Line Business Practice Location Address:
SCI 128
Provider Business Practice Location Address City Name:
HINES VA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-202-2702
Provider Business Practice Location Address Fax Number:
707-202-7960
Provider Enumeration Date:
07/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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