MEDICARE: JOHNNY WATKINS JR. DPT

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	225100000X	Physical Therapist	5501017308	MI

General Provider Information

NPI Number	:	1669840740
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHNNY WATKINS JR. DPT

Provider Business Mailing Address
First Line	:	6542 RUSTIC RIDGE TRL
Second Line	:
City	:	GRAND BLANC
State	:	MI
Zip	:	48439-4956
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6012 SOUTH LINDEN ROAD
Second Line	:	UNIT 15 MONTICELLO CENTER
City	:	SWARTZ CREEK
State	:	MI
Zip	:	48473-8889
Country	:	US
Telephone Number	:	810-655-8244
Fax Number	:	810-655-2192

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

Provider Enumeration Date	:	09/08/2015
Last Update Date	:	09/14/2016

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