MEDICARE: DIXIE LABORDE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	854241	NY

General Provider Information

NPI Number	:	1790216943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIXIE LABORDE

Provider Business Mailing Address
First Line	:	247 W 145TH ST
Second Line	:	APT3F
City	:	NEW YORK
State	:	NY
Zip	:	10039-4004
Country	:	US
Telephone Number	:	646-271-1475
Fax Number	:

Provider Business Practice Location Address
First Line	:	247 W 145TH ST
Second Line	:	APT 3F
City	:	NEW YORK
State	:	NY
Zip	:	10039-4004
Country	:	US
Telephone Number	:	646-271-1475
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2017
Last Update Date	:	03/21/2017

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Directions to “ DIXIE LABORDE ” Practice Location

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