Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 9558 | TX |
NPI | 1568465631 |
---|---|
Provider Name | Dr. Rex Dickerson |
First Address | Fredericksburg, TX 78624-5307 |
Second Address | Fredericksburg, TX 78624-5307 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/05/2005 |
Last Update Date | 05/05/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
608126 | BC & BS PROVIDER NUMBER (01) | TX |
V04103 | (02) | TX |