Provider Demographics
NPI:1316323165
Name:DIXIE STATE UNIVERSITY
Entity type:Organization
Organization Name:DIXIE STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:
Authorized Official - First Name:MOUZON
Authorized Official - Middle Name:
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-367-4845
Mailing Address - Street 1:PO BOX 650850
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0850
Mailing Address - Country:US
Mailing Address - Phone:800-555-9073
Mailing Address - Fax:972-367-3452
Practice Address - Street 1:225 S 700 E
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3875
Practice Address - Country:US
Practice Address - Phone:435-652-7850
Practice Address - Fax:972-367-3452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty