Healthcare Provider Details

I. General information

NPI: 1962916692
Provider Name (Legal Business Name): DIXIE LODGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2017
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10483 DIXIE HWY
HOLLY MI
48442-9311
US

IV. Provider business mailing address

805 N WHITTINGTON PKWY
LOUISVILLE KY
40222-7101
US

V. Phone/Fax

Practice location:
  • Phone: 810-866-4277
  • Fax:
Mailing address:
  • Phone: 800-866-0860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. MARGARET SHERRY PEMBERTON
Title or Position: VICE PRESIDENT
Credential:
Phone: 502-272-3466