Provider Demographics
NPI:1063943231
Name:JOHNSON, TABITHA
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3212 MARTIN LUTHER KING JR BOULEVARD
Mailing Address - Street 2:SUITE O
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29625
Mailing Address - Country:US
Mailing Address - Phone:864-540-8404
Mailing Address - Fax:864-540-8406
Practice Address - Street 1:3215 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:SUITE O
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29625-1715
Practice Address - Country:US
Practice Address - Phone:864-540-8404
Practice Address - Fax:864-540-8406
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist