Healthcare Provider Details

I. General information

NPI: 1639299746
Provider Name (Legal Business Name): DIXON SOCIAL INTERACTIVE SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 TRENT RD
NEW BERN NC
28562-5735
US

IV. Provider business mailing address

2105 KING LEAR CT
GREENVILLE NC
27858-8504
US

V. Phone/Fax

Practice location:
  • Phone: 252-353-0100
  • Fax:
Mailing address:
  • Phone: 252-258-8946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier8300651
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: MRS. DERRIA NOLEN DIXON
Title or Position: CFO
Credential:
Phone: 252-258-8946