Provider Demographics
NPI:1326762154
Name:CANTERBURY, JOHNNY DALE
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:DALE
Last Name:CANTERBURY
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 1:198 1ST STREET SE
Mailing Address - Street 2:
Mailing Address - City:ST. ALBANS
Mailing Address - State:WV
Mailing Address - Zip Code:25177
Mailing Address - Country:US
Mailing Address - Phone:304-205-3967
Mailing Address - Fax:
Practice Address - Street 1:518 22ND ST
Practice Address - Street 2:
Practice Address - City:DUNBAR
Practice Address - State:WV
Practice Address - Zip Code:25064-1712
Practice Address - Country:US
Practice Address - Phone:304-205-3967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant