Healthcare Provider Details

I. General information

NPI: 1356870158
Provider Name (Legal Business Name): BRIAN JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 06/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 SAINT PAULS RD
WARSAW VA
22572-4436
US

IV. Provider business mailing address

7443 LEE DAVIS ROAD SUITE 200
MECHANICSVILLE VA
23111
US

V. Phone/Fax

Practice location:
  • Phone: 804-761-4872
  • Fax: 804-493-8361
Mailing address:
  • Phone: 866-810-8305
  • Fax: 877-316-3453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: