Healthcare Provider Details

I. General information

NPI: 1568182343
Provider Name (Legal Business Name): MONROE DYSON SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2022
Last Update Date: 08/31/2022
Certification Date: 08/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6913 SOUTHAMPTON WAY
SACRAMENTO CA
95823-1937
US

IV. Provider business mailing address

6913 SOUTHAMPTON WAY
SACRAMENTO CA
95823-1937
US

V. Phone/Fax

Practice location:
  • Phone: 916-498-4905
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number342700446
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: