Healthcare Provider Details

I. General information

NPI: 1922698331
Provider Name (Legal Business Name): MR. BERNARD THORNTON JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2021
Last Update Date: 01/20/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 PERRY ST STE 241
NEWNAN GA
30263-1918
US

IV. Provider business mailing address

PO BOX 72306
NEWNAN GA
30271-2306
US

V. Phone/Fax

Practice location:
  • Phone: 678-789-8719
  • Fax: 470-241-1231
Mailing address:
  • Phone: 678-789-8719
  • Fax: 470-241-1231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code344600000X
TaxonomyTaxi
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: