1619933470 NPI number — JOHNSON LIFE CARE, INC

Table of content: (NPI 1619933470)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619933470 NPI number — JOHNSON LIFE CARE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHNSON LIFE CARE, INC
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:
JOHNSON LIFE CARE AMBULANCE
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:
1619933470
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 728
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LYNCH
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40855-0728
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-848-2861
Provider Business Mailing Address Fax Number:
606-848-2409

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 WEST MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYNCH
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40855
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-848-2861
Provider Business Practice Location Address Fax Number:
606-848-2409
Provider Enumeration Date:
04/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VANOVER
Authorized Official First Name:
DARREL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
606-848-2861

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  1609 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 56004179 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010121078 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 590011400 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1416591 . This is a "UNITED MINE WORKERS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000070292 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 089589600 . This is a "BLACK LUNG" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 4582350 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50011660 . This is a "PASSPORT HEALTH" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 55048078 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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