MEDICARE: MR. CORY 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	332B00000X	Durable Medical Equipment & Medical Supplies	11865	AL
2	343900000X	Non-emergency Medical Transport (VAN)	11865	AL

General Provider Information

NPI Number	:	1588097398
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CORY JOHNSON

Provider Business Mailing Address
First Line	:	150 E FLEMING RD
Second Line	:	2133 EAST ABERDEEN DR
City	:	MONTGOMERY
State	:	AL
Zip	:	36105-3208
Country	:	US
Telephone Number	:	334-294-6032
Fax Number	:

Provider Business Practice Location Address
First Line	:	2133 E ABERDEEN DR
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36116-1307
Country	:	US
Telephone Number	:	334-294-6032
Fax Number	:

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

Provider Enumeration Date	:	08/15/2013
Last Update Date	:	12/17/2015

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