Basic Information
| Provider Information | |||||||||
| NPI: | 1063599512 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNS | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | HERBERT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.AUD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 WELLNESS BLVD | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | IRMO | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290632871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037651919 | ||||||||
| FaxNumber: | 8037493371 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 RICHLAND MEDICAL PARK DR | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037651919 | ||||||||
| FaxNumber: | 8037719084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 10/16/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 1067 | SC | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | SA0061 | 05 | SC | MEDICAID |