Provider Demographics
NPI:1558797639
Name:DIXON CORRECTIONAL INSTITUTE
Entity Type:Organization
Organization Name:DIXON CORRECTIONAL INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELO
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:TARVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-634-6311
Mailing Address - Street 1:5085 CREEK VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791
Mailing Address - Country:US
Mailing Address - Phone:225-610-7403
Mailing Address - Fax:
Practice Address - Street 1:5085 CREEK VALLEY DR
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-3073
Practice Address - Country:US
Practice Address - Phone:225-610-7403
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07348261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center