Healthcare Provider Details

I. General information

NPI: 1225451370
Provider Name (Legal Business Name): MR. GRANT EDWARD JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2014
Last Update Date: 01/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 HILLTOP ST
GIBSLAND LA
71028
US

IV. Provider business mailing address

P O BOX 423 1221 HILLTOP ST
GIBSLAND LA
71028
US

V. Phone/Fax

Practice location:
  • Phone: 318-843-6090
  • Fax: 318-843-6090
Mailing address:
  • Phone: 318-843-6090
  • Fax: 318-843-6090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number41235361K
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number008591754
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: