1346766862 NPI number — MRS. VICTORIA G JOHNSON LBA

Table of content: MRS. VICTORIA G JOHNSON LBA (NPI 1346766862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346766862 NPI number — MRS. VICTORIA G JOHNSON LBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
VICTORIA
Provider Middle Name:
G
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LBA
Provider Gender Code:
F

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:
1346766862
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3411 WHITMAN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSHARON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77583-1204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-676-2557
Provider Business Mailing Address Fax Number:
318-855-1277

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4210 BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEARLAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77581-4118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-600-6640
Provider Business Practice Location Address Fax Number:
318-855-1277
Provider Enumeration Date:
08/16/2017

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: 103K00000X , with the licence number:  L-219 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: L-219 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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