Healthcare Provider Details

I. General information

NPI: 1194042499
Provider Name (Legal Business Name): TERRY JOHNSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2010
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5908 EASTMAN AVE
MIDLAND MI
48640-6748
US

IV. Provider business mailing address

5908 EASTMAN AVE
MIDLAND MI
48640-6748
US

V. Phone/Fax

Practice location:
  • Phone: 989-636-7200
  • Fax: 989-636-7210
Mailing address:
  • Phone: 989-636-7200
  • Fax: 989-636-7210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number4901002282
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number4901002282
License Number StateMI

VIII. Authorized Official

Name: MRS. DENISE E. BURCH
Title or Position: OFFICE MANAGER
Credential:
Phone: 989-636-7200