Provider Demographics
NPI:1235509829
Name:DIXON FAMILY MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:DIXON FAMILY MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:BIANCA
Authorized Official - Last Name:DECLOUET-DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:337-628-5014
Mailing Address - Street 1:PO BOX 596
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70589-0596
Mailing Address - Country:US
Mailing Address - Phone:337-628-5014
Mailing Address - Fax:337-826-5401
Practice Address - Street 1:536 ST. LANDRY VETERANS MEMORIAL HWY.
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:LA
Practice Address - Zip Code:70589-4420
Practice Address - Country:US
Practice Address - Phone:337-628-5014
Practice Address - Fax:337-826-5401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-25
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP05959363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1820105Medicaid