MEDICARE: CHARLOTTE MATTEA JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier		FL

General Provider Information

NPI Number	:	1396585378
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLOTTE MATTEA JOHNSON

Provider Business Mailing Address
First Line	:	4951 NW 18TH ST
Second Line	:
City	:	LAUDERHILL
State	:	FL
Zip	:	33313-4117
Country	:	US
Telephone Number	:	754-213-1031
Fax Number	:

Provider Business Practice Location Address
First Line	:	1314 E LAS OLAS BLVD
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33301-2334
Country	:	US
Telephone Number	:	754-213-1031
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2024
Last Update Date	:	05/30/2024

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