1376837260 NPI number — JOHNSON CLINIC OF COVINGTON, INC

Table of content: (NPI 1376837260)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376837260 NPI number — JOHNSON CLINIC OF COVINGTON, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHNSON CLINIC OF COVINGTON, 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:
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:
1376837260
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 507
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COVINGTON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38019-0507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-475-4752
Provider Business Mailing Address Fax Number:
901-475-1554

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4235 HIGHWAY 51 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIGHTON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38011-6921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-475-4752
Provider Business Practice Location Address Fax Number:
901-475-1554
Provider Enumeration Date:
06/08/2011

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
SAMUEL
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
901-475-4752

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD11374 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com