Healthcare Provider Details

I. General information

NPI: 1578764965
Provider Name (Legal Business Name): MR. HENDERSON JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 SOUTH COURT ST
OPELOUSAS LA
70570
US

IV. Provider business mailing address

PO BOX 671
OPELOUSAS LA
70571-0671
US

V. Phone/Fax

Practice location:
  • Phone: 337-948-4481
  • Fax: 337-948-4437
Mailing address:
  • Phone: 337-948-4481
  • Fax: 337-948-4437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License NumberCLP.200901-PHL
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: