Provider Demographics
NPI:1518522796
Name:JOHNSON, CHARLES LEE SR
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LEE
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 1:2010 PARKHILL DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-2716
Mailing Address - Country:US
Mailing Address - Phone:937-559-2669
Mailing Address - Fax:937-723-7435
Practice Address - Street 1:2010 PARKHILL DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-2716
Practice Address - Country:US
Practice Address - Phone:937-559-2669
Practice Address - Fax:937-723-7435
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-03
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider