MEDICARE: MR. DENNIS R JOHNSON

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	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)

General Provider Information

NPI Number	:	1447447024
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DENNIS R JOHNSON

Provider Business Mailing Address
First Line	:	2053 STANTON RD
Second Line	:
City	:	EAST POINT
State	:	GA
Zip	:	30344-1311
Country	:	US
Telephone Number	:	404-768-2030
Fax Number	:

Provider Business Practice Location Address
First Line	:	2053 STANTON RD
Second Line	:
City	:	EAST POINT
State	:	GA
Zip	:	30344-1311
Country	:	US
Telephone Number	:	404-768-2030
Fax Number	:

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

Provider Enumeration Date	:	09/27/2007
Last Update Date	:	09/27/2007

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