Provider Demographics
NPI:1003268236
Name:JOHNSON I-CARE, LLC
Entity Type:Organization
Organization Name:JOHNSON I-CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:615-497-5512
Mailing Address - Street 1:1024 GLENBROOK WAY
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-1230
Mailing Address - Country:US
Mailing Address - Phone:615-822-8464
Mailing Address - Fax:615-822-8465
Practice Address - Street 1:1024 GLENBROOK WAY
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-1230
Practice Address - Country:US
Practice Address - Phone:615-822-8464
Practice Address - Fax:615-822-8465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-12
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN2419152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ022814Medicaid