Provider Demographics
NPI:1598097974
Name:JOHNSON, LATAURUS
Entity Type:Individual
Prefix:
First Name:LATAURUS
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 N DALLAS AVE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:TX
Mailing Address - Zip Code:75146-1616
Mailing Address - Country:US
Mailing Address - Phone:972-218-2272
Mailing Address - Fax:972-218-8023
Practice Address - Street 1:918 N DALLAS AVE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:TX
Practice Address - Zip Code:75146-1616
Practice Address - Country:US
Practice Address - Phone:972-218-2272
Practice Address - Fax:214-218-8023
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-09
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008833291U00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX457869Medicare PIN