=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205312352
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIXIE INFUSION CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2018
-----------------------------------------------------
Last Update Date | 09/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 650 W LINCOLN TRAIL BLVD STE 102
-----------------------------------------------------
City | RADCLIFF
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40160-2681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-506-2463
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 650 W LINCOLN TRAIL BLVD STE 102
-----------------------------------------------------
City | RADCLIFF
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40160-2681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-506-2463
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NAVAS YOONUS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-525-3142
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QI0500X
-----------------------------------------------------
Taxonomy Name | Infusion Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------