Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 27043 | CA |
NPI | 1285719419 |
---|---|
Provider Name | Dr. John Russel Dixon |
First Address | Palm Desert, CA 92211-0483 |
Second Address | Palm Desert, CA 92211-0483 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/10/2006 |
Last Update Date | 09/10/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T60479 | (02) | CA |