Provider Demographics
NPI:1194089219
Name:JOHNSON ATHLETIC ADVANTAGE
Entity type:Organization
Organization Name:JOHNSON ATHLETIC ADVANTAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CODY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:214-383-0623
Mailing Address - Street 1:820 S ALMA DR
Mailing Address - Street 2:STE. 110
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-3808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:820 S ALMA DR STE 110
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-3810
Practice Address - Country:US
Practice Address - Phone:214-383-0623
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-03
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1152858261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy