Healthcare Provider Details

I. General information

NPI: 1710704630
Provider Name (Legal Business Name): JUSTIN JOHNSON ROYAL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

197 MADISON HEIGHTS SQ
MADISON HEIGHTS VA
24572-6243
US

IV. Provider business mailing address

197 MADISON HEIGHTS SQ
MADISON HEIGHTS VA
24572-6243
US

V. Phone/Fax

Practice location:
  • Phone: 434-846-8288
  • Fax: 434-846-5691
Mailing address:
  • Phone: 434-846-8288
  • Fax: 434-846-5691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number1101004417
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: