1376838110 NPI number — LINDA L. JOHNSON MD, LTD

Table of content: DR. ABBY MCCLELLAN TIBBITTS DMD (NPI 1528553732)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376838110 NPI number — LINDA L. JOHNSON MD, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LINDA L. JOHNSON MD, LTD
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:
6
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:
1376838110
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2720 N TENAYA WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89128-0424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-560-2889
Provider Business Mailing Address Fax Number:
702-560-2928

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 E LAKE MEAD PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89015-5576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-560-2915
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/09/2011

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
SMA PRESIDENT
Authorized Official Telephone Number:
702-560-2886

Provider Taxonomy Codes

  • Taxonomy code: 207QA0505X , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1376838110 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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