MEDICARE: GROVER CLEVELAND JOHNSON IV

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	2018037368	MO

General Provider Information

NPI Number	:	1023759206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GROVER CLEVELAND JOHNSON IV

Provider Business Mailing Address
First Line	:	7530 ENON RD
Second Line	:
City	:	RUSSELLVILLE
State	:	MO
Zip	:	65074-2602
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3600 COUNTRY CLUB DR STE 530A
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65109-1060
Country	:	US
Telephone Number	:	573-606-7100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2022
Last Update Date	:	04/05/2022

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