MEDICARE: DIXIE HOPPER

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	347C00000X	Private Vehicle

General Provider Information

NPI Number	:	1578778718
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIXIE HOPPER

Provider Business Mailing Address
First Line	:	1509 COLUMBUS ST
Second Line	:
City	:	MUSKOGEE
State	:	OK
Zip	:	74401-6730
Country	:	US
Telephone Number	:	918-687-5057
Fax Number	:

Provider Business Practice Location Address
First Line	:	1509 COLUMBUS ST
Second Line	:
City	:	MUSKOGEE
State	:	OK
Zip	:	74401-6730
Country	:	US
Telephone Number	:	918-687-5057
Fax Number	:

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

Provider Enumeration Date	:	05/11/2007
Last Update Date	:	07/09/2007

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Directions to “ DIXIE HOPPER ” Practice Location

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