MEDICARE: S. JOHNSON HOME CARE ASSISTANCE LLC

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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1356916613
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	S. JOHNSON HOME CARE ASSISTANCE LLC

Provider Business Mailing Address
First Line	:	7414 PAGE RANCH CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89131-3244
Country	:	US
Telephone Number	:	419-699-6769
Fax Number	:

Provider Business Practice Location Address
First Line	:	7414 PAGE RANCH CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89131-3244
Country	:	US
Telephone Number	:	419-699-6769
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	SHAWANDA JOHNSON
Credential	:
Telephone Number	:	419-699-6769

Provider Enumeration Date	:	05/20/2021
Last Update Date	:	05/20/2021

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