1104328806 NPI number — YALONDA E DIXON

Table of content: YALONDA E DIXON (NPI 1104328806)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104328806 NPI number — YALONDA E DIXON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIXON
Provider First Name:
YALONDA
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1104328806
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
224 COLUMBUS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45701-1334
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-592-6724
Provider Business Mailing Address Fax Number:
740-592-6728

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10050 BASSETT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45701-3626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-594-8108
Provider Business Practice Location Address Fax Number:
740-594-0268
Provider Enumeration Date:
03/08/2018

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: 101YA0400X , with the licence number:  120909 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2864002 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com