Healthcare Provider Details

I. General information

NPI: 1710185376
Provider Name (Legal Business Name): PHILLIP W JOHNSON CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 12/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 S MAIN ST SUITE A
BLACKSBURG VA
24060-7019
US

IV. Provider business mailing address

3635 S MAIN ST SUITE A
BLACKSBURG VA
24060-7019
US

V. Phone/Fax

Practice location:
  • Phone: 540-951-2566
  • Fax: 540-951-7818
Mailing address:
  • Phone: 540-951-2566
  • Fax: 540-951-7818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberCPO 02395
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCPO 02395
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: