Provider Demographics
NPI:1003099029
Name:WILLIE N DIXON
Entity Type:Organization
Organization Name:WILLIE N DIXON
Other - Org Name:SHEPHERD GROVE FAMILY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:N
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-243-9827
Mailing Address - Street 1:2817 TILGHMAN RD N
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27896-8908
Mailing Address - Country:US
Mailing Address - Phone:252-243-9827
Mailing Address - Fax:252-291-9448
Practice Address - Street 1:2817 TILGHMAN RD N
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27896-8908
Practice Address - Country:US
Practice Address - Phone:252-243-9827
Practice Address - Fax:252-291-9448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-098-009310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7801424Medicaid