MEDICARE: CARLA ANN DICKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	2676733	OH

General Provider Information

NPI Number	:	1245360569
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLA ANN DICKSON

Provider Business Mailing Address
First Line	:	101 E MAPLE AVE
Second Line	:
City	:	NEW CONCORD
State	:	OH
Zip	:	43762-1222
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 E MAPLE AVE
Second Line	:
City	:	NEW CONCORD
State	:	OH
Zip	:	43762-1222
Country	:	US
Telephone Number	:	740-260-1281
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	07/08/2007

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