Healthcare Provider Details

I. General information

NPI: 1649389388
Provider Name (Legal Business Name): MARY DIANE JOHNSON TMD OUTLET
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 S MONROE
LEBANON MO
65536-3570
US

IV. Provider business mailing address

702 S MONROE
LEBANON MO
65536-3570
US

V. Phone/Fax

Practice location:
  • Phone: 417-588-3404
  • Fax: 417-588-3404
Mailing address:
  • Phone: 417-588-3404
  • Fax: 417-588-3404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARY D JOHNSON
Title or Position: OWNER/ABC CERTIFIED FITTER (REM0094
Credential:
Phone: 417-588-3404