=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558797639
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIXON CORRECTIONAL INSTITUTE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2013
-----------------------------------------------------
Last Update Date | 09/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5085 CREEK VALLEY DR
-----------------------------------------------------
City | ZACHARY
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70791-3073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-610-7403
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5085 CREEK VALLEY DR
-----------------------------------------------------
City | ZACHARY
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70791
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-610-7403
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | ANGELO ANTHONY TARVER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 225-634-6311
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | AP07348
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------