MEDICARE: MRS. DIXIE STORY CM

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	175M00000X	Lay Midwife	602	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	667411	OTHER	NV	PREFERRED PROVIDER ID #

General Provider Information

NPI Number	:	1265642359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DIXIE STORY CM

Provider Business Mailing Address
First Line	:	6103 JUDSON AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89156-5821
Country	:	US
Telephone Number	:	702-453-3299
Fax Number	:	702-452-0384

Provider Business Practice Location Address
First Line	:	6103 JUDSON AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89156-5821
Country	:	US
Telephone Number	:	702-453-3299
Fax Number	:	702-452-0384

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

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	07/08/2007

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