Healthcare Provider Details

I. General information

NPI: 1104117571
Provider Name (Legal Business Name): DEREK JOHNSON L.AC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2011
Last Update Date: 04/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7433 MONTGOMERY RD
CINCINNATI OH
45236-4160
US

IV. Provider business mailing address

802 W MAIN ST
LOVELAND OH
45140-2508
US

V. Phone/Fax

Practice location:
  • Phone: 513-439-4761
  • Fax:
Mailing address:
  • Phone: 513-439-4761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number65.000200
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: