MEDICARE: DIXON RECOVERY INSTITUTE, INC.

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	190622AN	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7336	OTHER	CA	DRUG MEDI-CAL

General Provider Information

NPI Number	:	1780814640
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIXON RECOVERY INSTITUTE, INC.

Provider Business Mailing Address
First Line	:	4715 CRENSHAW BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90043-1233
Country	:	US
Telephone Number	:	323-988-3744
Fax Number	:	323-988-9672

Provider Business Practice Location Address
First Line	:	4066 W 17TH ST
Second Line	:	MODULE #1 & 2
City	:	LOS ANGELES
State	:	CA
Zip	:	90019-6025
Country	:	US
Telephone Number	:	323-988-3744
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	RONDA DIXON
Credential	:	JD
Telephone Number	:	323-988-3744

Provider Enumeration Date	:	07/24/2009
Last Update Date	:	05/07/2012

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