Healthcare Provider Details

I. General information

NPI: 1801767637
Provider Name (Legal Business Name): DIXIE HOLSTEN PPRC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2025
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 N 3RD AVE STE 330
POCATELLO ID
83201-6369
US

IV. Provider business mailing address

5055 ARAPAHOE ST
POCATELLO ID
83204-3773
US

V. Phone/Fax

Practice location:
  • Phone: 208-242-3771
  • Fax: 208-242-3772
Mailing address:
  • Phone: 208-242-3771
  • Fax: 208-242-3772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number13184
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: