Healthcare Provider Details

I. General information

NPI: 1174036800
Provider Name (Legal Business Name): DANE G JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2017
Last Update Date: 11/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 LAKESHORE DR
CHARLESTON SC
29412-2017
US

IV. Provider business mailing address

2021 LAKESHORE DR
CHARLESTON SC
29412-2017
US

V. Phone/Fax

Practice location:
  • Phone: 703-851-9556
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: