1356729321 NPI number — JOHNNY JEFFREY LAWRENCE

Table of content: JOHNNY JEFFREY LAWRENCE (NPI 1356729321)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356729321 NPI number — JOHNNY JEFFREY LAWRENCE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAWRENCE
Provider First Name:
JOHNNY
Provider Middle Name:
JEFFREY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LAWRENCE
Provider Other First Name:
JOHN
Provider Other Middle Name:
JEFFREY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
JR.
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1356729321
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 S JACKSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40202-1622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-852-3751
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3300 GALLOWS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FALLS CHURCH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22042-3307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-776-7113
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/11/2015

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: 0101268082 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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