1609076645 NPI number — JOHNSON AND KEENE MD PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609076645 NPI number — JOHNSON AND KEENE MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHNSON AND KEENE MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FULL CIRCLE HEALTH ASSOCIATES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609076645
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2030 MOUNTAIN VIEW AVENUE
Provider Second Line Business Mailing Address:
SUITE 540
Provider Business Mailing Address City Name:
LONGMONT
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80501-3183
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-682-1112
Provider Business Mailing Address Fax Number:
303-702-5935

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2030 MOUNTAIN VIEW AVENUE
Provider Second Line Business Practice Location Address:
SUITE 540
Provider Business Practice Location Address City Name:
LONGMONT
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80501-3183
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-682-1112
Provider Business Practice Location Address Fax Number:
303-702-5935
Provider Enumeration Date:
07/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
AMY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
303-682-1112

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 12979554 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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