Provider Demographics
NPI:1740582212
Name:DIXON SOCIAL INTERACTIVE SERVICES, INC.
Entity Type:Organization
Organization Name:DIXON SOCIAL INTERACTIVE SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DERRIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-353-0100
Mailing Address - Street 1:PO BOX 30166
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27833-0166
Mailing Address - Country:US
Mailing Address - Phone:252-353-0100
Mailing Address - Fax:
Practice Address - Street 1:1202-B VERNON AVENUE
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501
Practice Address - Country:US
Practice Address - Phone:252-353-0100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-03
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-074-163251S00000X
NCMHL-054-145251S00000X
NCMHL-025-018251S00000X
NCMHL-025-220251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300653Medicaid
NC5912833Medicaid
NC8300651Medicaid
NC6005438Medicaid
NC8302839Medicaid
NC8300652Medicaid