Provider Demographics
NPI:1225451370
Name:JOHNSON, GRANT EDWARD
Entity Type:Individual
Prefix:MR
First Name:GRANT
Middle Name:EDWARD
Last Name:JOHNSON
Suffix:
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:P O BOX 423
Mailing Address - Street 2:1221 HILLTOP ST
Mailing Address - City:GIBSLAND
Mailing Address - State:LA
Mailing Address - Zip Code:71028
Mailing Address - Country:US
Mailing Address - Phone:318-843-6090
Mailing Address - Fax:318-843-6090
Practice Address - Street 1:1221 HILLTOP ST
Practice Address - Street 2:
Practice Address - City:GIBSLAND
Practice Address - State:LA
Practice Address - Zip Code:71028
Practice Address - Country:US
Practice Address - Phone:318-843-6090
Practice Address - Fax:318-843-6090
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA008591754172A00000X
LA41235361K343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No172A00000XOther Service ProvidersDriver