Healthcare Provider Details

I. General information

NPI: 1508455841
Provider Name (Legal Business Name): BRANDON JOHNSON ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2429 5TH ST N
COLUMBUS MS
39705-2005
US

IV. Provider business mailing address

2429 5TH ST N
COLUMBUS MS
39705-2005
US

V. Phone/Fax

Practice location:
  • Phone: 662-328-4542
  • Fax:
Mailing address:
  • Phone: 662-328-4542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT0305
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: