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General NPI Number Information
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NPI Number | 1801517651
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Entity Type | Individual
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Provider Name | WILLIE JOHNSON GM
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Gender | Male
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Dates
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Enumeration Date | 09/09/2022
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Last Update Date | 09/09/2022
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Provider Practice Location Address
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Address Line | 108 JULIE LN
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City | AUBURNDALE
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State | FL
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Zip | 33823-2335
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Country | US
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Telephone | 863-269-8897
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Fax |
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Provider Business Mailing Address
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Address Line | 23781 HWY 27 # 226
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City | LAKE WALES
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State | FL
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Zip | 33859-7802
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Country | US
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Telephone | 863-269-8897
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BP3500X
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Taxonomy Name | Parenteral & Enteral Nutrition Supplies (DME)
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License Number | 207693
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number | 207683
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License Number State | FL
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