MEDICARE: MANITA YVETTE 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	171WH0202X	Home Modifications Contractor		NC

General Provider Information

NPI Number	:	1710110168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MANITA YVETTE JOHNSON

Provider Business Mailing Address
First Line	:	3125 EASTWAY DR
Second Line	:	SUITE 213
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-5643
Country	:	US
Telephone Number	:	704-621-2201
Fax Number	:	704-900-6140

Provider Business Practice Location Address
First Line	:	3125 EASTWAY DR
Second Line	:	SUITE 213
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-5643
Country	:	US
Telephone Number	:	704-621-2201
Fax Number	:	704-900-6140

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

Provider Enumeration Date	:	09/02/2009
Last Update Date	:	09/02/2009

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