MEDICARE: MR. CHARLES MILLER JOHNSON JR. LVN

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	164W00000X	Licensed Practical Nurse	300231	NY
2	164X00000X	Licensed Vocational Nurse	VN251826	CA

General Provider Information

NPI Number	:	1063744571
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES MILLER JOHNSON JR. LVN

Provider Business Mailing Address
First Line	:	1020 ROBINSON AVE APT 2
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-4473
Country	:	US
Telephone Number	:	619-581-4410
Fax Number	:

Provider Business Practice Location Address
First Line	:	1020 ROBINSON AVE APT 2
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-4473
Country	:	US
Telephone Number	:	619-581-4410
Fax Number	:

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

Provider Enumeration Date	:	02/08/2010
Last Update Date	:	02/03/2014

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