Basic Information
| Provider Information | |||||||||
| NPI: | 1316926538 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHNSON HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 134 ELON RD | ||||||||
| Address2: | |||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245722536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4344552480 | ||||||||
| FaxNumber: | 4344552487 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 FEDERAL ST | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245042306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349475967 | ||||||||
| FaxNumber: | 4349475255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2006 | ||||||||
| LastUpdateDate: | 04/07/2015 | ||||||||
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| AuthorizedOfficialLastName: | CAMPBELL | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4344552480 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 010064988 | 05 | VA | MEDICAID | DC4704 | 01 | VA | RAILROAD MEDICARE | OTHER |