Basic Information
| Provider Information | |||||||||
| NPI: | 1508231036 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHNSON HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AMELON SQUARE IMMEDIATE CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4649 | ||||||||
| Address2: | |||||||||
| City: | GLEN ALLEN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 230584649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349475967 | ||||||||
| FaxNumber: | 4344552486 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 AMELON SQ | ||||||||
| Address2: | |||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245725981 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349491400 | ||||||||
| FaxNumber: | 4349475971 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2015 | ||||||||
| LastUpdateDate: | 12/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | CAMPBELL | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| 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.