Basic Information
| Provider Information | |||||||||
| NPI: | 1467570168 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHNSON HEALTH CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | BROOKNEAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 CAROLINA AVENUE | ||||||||
| Address2: | |||||||||
| City: | BROOKNEAL | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4343762325 | ||||||||
| FaxNumber: | 4343762081 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 CAROLINA AVENUE | ||||||||
| Address2: | |||||||||
| City: | BROOKNEAL | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4343762325 | ||||||||
| FaxNumber: | 4343762081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SNIEZEK | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4349475967 | ||||||||
| IsSoleProprietor: | |||||||||
| 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) |
No ID Information.