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General NPI Number Information
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NPI Number | 1417028135
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Entity Type | Organization
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Legal Business Name | DIXIE REST HOME 1
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Dates
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Enumeration Date | 11/13/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 310 NORTH MARTIN LUTHER KING AVENUE
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City | ENFIELD
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State | NC
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Zip | 27823
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Country | US
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Telephone | 252-445-5665
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Fax | 252-445-3466
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Provider Business Mailing Address
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Address Line | PO BOX 129 310 NORTH MARTIN LUTHER KING AVENUE
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City | ENFIELD
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State | NC
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Zip | 27823
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Country | US
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Telephone | 252-445-5665
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Fax | 252-445-3466
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. RONALD W WOOD
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Credential | PRESIDENT
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Telephone | 252-445-5665
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | HAL042002
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License Number State | NC
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