Provider Demographics
NPI:1093103491
Name:JOHNSON, LARRY SR
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:JOHNSON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 LAKE AIR DR
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-5887
Mailing Address - Country:US
Mailing Address - Phone:254-224-6208
Mailing Address - Fax:
Practice Address - Street 1:600 LAKE AIR DR
Practice Address - Street 2:SUITE 3A
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-5887
Practice Address - Country:US
Practice Address - Phone:254-224-6208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36634675347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle