Healthcare Provider Details

I. General information

NPI: 1124582051
Provider Name (Legal Business Name): MYLES ALEXANDER JOHNSON EP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2019
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 W BROAD ST
RICHMOND VA
23230-4915
US

IV. Provider business mailing address

11420 SETHWARNER DR
GLEN ALLEN VA
23059-4802
US

V. Phone/Fax

Practice location:
  • Phone: 804-585-6723
  • Fax:
Mailing address:
  • Phone: 804-929-0405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: