Provider Demographics
NPI:1588097398
Name:JOHNSON, CORY
Entity type:Individual
Prefix:MR
First Name:CORY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JOSHUA
Other - Middle Name:
Other - Last Name:AGENCY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:150 E FLEMING RD
Mailing Address - Street 2:2133 EAST ABERDEEN DR
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36105-3208
Mailing Address - Country:US
Mailing Address - Phone:334-294-6032
Mailing Address - Fax:
Practice Address - Street 1:2133 E ABERDEEN DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-1307
Practice Address - Country:US
Practice Address - Phone:334-294-6032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-15
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11865332B00000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)