Provider Demographics
NPI:1215471255
Name:JOHNSON, JOHNNY L
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 WESTON ST
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:LA
Mailing Address - Zip Code:71055-3662
Mailing Address - Country:US
Mailing Address - Phone:318-272-2722
Mailing Address - Fax:318-299-8218
Practice Address - Street 1:702 WESTON ST
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:LA
Practice Address - Zip Code:71055-3662
Practice Address - Country:US
Practice Address - Phone:318-272-2722
Practice Address - Fax:318-299-8218
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-09
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10197359343900000X
343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)