Healthcare Provider Details

I. General information

NPI: 1306201868
Provider Name (Legal Business Name): AMMON JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2015
Last Update Date: 12/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6831 S DANTE AVE
CHICAGO IL
60637-4830
US

IV. Provider business mailing address

6831 S DANTE AVE
CHICAGO IL
60637-4830
US

V. Phone/Fax

Practice location:
  • Phone: 312-320-9475
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: