=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619933470
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHNSON LIFE CARE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2006
-----------------------------------------------------
Last Update Date | 11/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 WEST MAIN STREET
-----------------------------------------------------
City | LYNCH
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40855
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-848-2861
-----------------------------------------------------
Fax | 606-848-2409
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 728
-----------------------------------------------------
City | LYNCH
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40855-0728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-848-2861
-----------------------------------------------------
Fax | 606-848-2409
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. DARREL VANOVER
-----------------------------------------------------
Credential | EMT
-----------------------------------------------------
Telephone | 606-848-2861
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 1609
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------