Healthcare Provider Details

I. General information

NPI: 1134630957
Provider Name (Legal Business Name): EDDIE JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2017
Last Update Date: 10/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 BOND ST
LONE STAR TX
75668-0230
US

IV. Provider business mailing address

PO BOX 124
LONE STAR TX
75668-0124
US

V. Phone/Fax

Practice location:
  • Phone: 903-646-3171
  • Fax: 903-646-0512
Mailing address:
  • Phone: 903-646-3171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: