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General NPI Number Information
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NPI Number | 1902264492
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Entity Type | Individual
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Provider Name | MR. TY-RE LAMONT DIXON SR.
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Gender | Male
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Dates
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Enumeration Date | 01/29/2016
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Last Update Date | 01/29/2016
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Provider Practice Location Address
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Address Line | 220 SHORELINE DR.
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City | FAYETTEVILLE
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State | GA
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Zip | 30215
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Country | US
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Telephone | 404-661-1800
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Fax | 770-897-3777
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Provider Business Mailing Address
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Address Line | 220 SHORELINE DR.
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City | FAYETTEVILLE
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State | GA
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Zip | 30215
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Country | US
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Telephone | 404-661-1800
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Fax | 770-897-3777
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number |
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License Number State | GA
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