1124477658 NPI number — JOHNATHAN ANTONIO BRUNSON LCAS-A

Table of content: JOHNATHAN ANTONIO BRUNSON LCAS-A (NPI 1124477658)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124477658 NPI number — JOHNATHAN ANTONIO BRUNSON LCAS-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUNSON
Provider First Name:
JOHNATHAN
Provider Middle Name:
ANTONIO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCAS-A
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:
1124477658
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
307 BEECH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOLDSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27530-2818
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-731-2119
Provider Business Mailing Address Fax Number:
919-739-4989

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3011 NC HIGHWAY 42 W
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
WILSON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27893
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-991-3985
Provider Business Practice Location Address Fax Number:
252-991-3993
Provider Enumeration Date:
06/06/2016

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: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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