Healthcare Provider Details

I. General information

NPI: 1417971433
Provider Name (Legal Business Name): ERIC JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 NORTH STATE STREET
ROCHESTER WI
53167-0386
US

IV. Provider business mailing address

PO BOX 386
ROCHESTER WI
53167-0386
US

V. Phone/Fax

Practice location:
  • Phone: 262-331-4397
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5627
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: