Healthcare Provider Details

I. General information

NPI: 1346432556
Provider Name (Legal Business Name): BLANE JOHNSON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2007
Last Update Date: 01/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

939 S 25TH E SUITE 100
AMMON ID
83406-5734
US

IV. Provider business mailing address

939 S 25TH E SUITE 100
AMMON ID
83406-5734
US

V. Phone/Fax

Practice location:
  • Phone: 208-525-3338
  • Fax: 208-525-3339
Mailing address:
  • Phone: 208-525-3338
  • Fax: 208-525-3339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateID

VIII. Authorized Official

Name: MR. BLANE ROBERT JOHNSON
Title or Position: OWNER/DIRECTOR
Credential:
Phone: 208-525-3382