Provider Demographics
NPI:1457025140
Name:JOHNSON, ROY H III
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:H
Last Name:JOHNSON
Suffix:III
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 1:3732 TEMPLE DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-1537
Mailing Address - Country:US
Mailing Address - Phone:571-217-1353
Mailing Address - Fax:
Practice Address - Street 1:2375 PROFESSIONAL HEIGHTS DR STE 260
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3053
Practice Address - Country:US
Practice Address - Phone:859-227-8546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY106267225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist