MEDICARE: DOROTHY LAURA 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	332900000X	Non-Pharmacy Dispensing Site	NT00000639	WA

General Provider Information

NPI Number	:	1528467289
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOROTHY LAURA JOHNSON

Provider Business Mailing Address
First Line	:	2980 N BEVERLY GLEN CIR
Second Line	:	SUITE # 301
City	:	LOS ANGELES
State	:	CA
Zip	:	90077-1726
Country	:	US
Telephone Number	:	310-943-4180
Fax Number	:	888-431-8819

Provider Business Practice Location Address
First Line	:	5611 119TH AVE SE
Second Line	:	SUITE 4
City	:	BELLEVUE
State	:	WA
Zip	:	98006-3799
Country	:	US
Telephone Number	:	425-562-9355
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DOROTHY L. JOHNSON
Credential	:	N.D.
Telephone Number	:	425-562-9355

Provider Enumeration Date	:	08/19/2014
Last Update Date	:	08/19/2014

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