MEDICARE: TIMOTHY L. JOHNSON ACADEMY

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	251300000X	Local Education Agency (LEA)	9350	IN

General Provider Information

NPI Number	:	1285771691
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIMOTHY L. JOHNSON ACADEMY

Provider Business Mailing Address
First Line	:	7908 S ANTHONY BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46816-2504
Country	:	US
Telephone Number	:	260-441-8727
Fax Number	:	260-441-9357

Provider Business Practice Location Address
First Line	:	7908 S ANTHONY BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46816-2504
Country	:	US
Telephone Number	:	260-441-8727
Fax Number	:	260-441-9357

Authorized Official
Title or Position	:	SCHOOL LEADER
Name	:	MR. STEVE BOLLIER
Credential	:
Telephone Number	:	260-441-8727

Provider Enumeration Date	:	02/01/2007
Last Update Date	:	08/22/2020

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