Healthcare Provider Details

I. General information

NPI: 1013342195
Provider Name (Legal Business Name): CHARLES DAVID JOHNS RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2013
Last Update Date: 09/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 RAILROAD ST
BANGOR MI
49013-1464
US

IV. Provider business mailing address

4929 BRADEN ST
GRAND JUNCTION MI
49056-9249
US

V. Phone/Fax

Practice location:
  • Phone: 269-427-6171
  • Fax: 866-242-4929
Mailing address:
  • Phone: 269-605-9103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704265201
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: