=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528495868
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOYCIE M JOHNSON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2013
-----------------------------------------------------
Last Update Date | 01/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2698 HESTER AVE SE SAME
-----------------------------------------------------
City | PALM BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32909-7607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-327-2718
-----------------------------------------------------
Fax | 321-727-8811
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2698 HESTER AVE SE
-----------------------------------------------------
City | PALM BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32909-7607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-327-2718
-----------------------------------------------------
Fax | 321-727-8811
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | MISS JOYCIE MAY JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 321-327-2718
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 6906635
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------