1669840740 NPI number — JOHNNY WATKINS JR. DPT

Table of content: JOHNNY WATKINS JR. DPT (NPI 1669840740)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669840740 NPI number — JOHNNY WATKINS JR. DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATKINS
Provider First Name:
JOHNNY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
DPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1669840740
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6542 RUSTIC RIDGE TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND BLANC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48439-4956
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6012 SOUTH LINDEN ROAD
Provider Second Line Business Practice Location Address:
UNIT 15 MONTICELLO CENTER
Provider Business Practice Location Address City Name:
SWARTZ CREEK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48473-8889
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-655-8244
Provider Business Practice Location Address Fax Number:
810-655-2192
Provider Enumeration Date:
09/08/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  5501017308 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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