Healthcare Provider Details

I. General information

NPI: 1831073386
Provider Name (Legal Business Name): CALVIN JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2025
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008A MASTERS LN
GREENVILLE NC
27834-8015
US

IV. Provider business mailing address

1008A MASTERS LN
GREENVILLE NC
27834-8015
US

V. Phone/Fax

Practice location:
  • Phone: 252-814-8789
  • Fax:
Mailing address:
  • Phone: 252-814-8789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: