Provider Demographics
NPI:1619933470
Name:JOHNSON LIFE CARE, INC
Entity Type:Organization
Organization Name:JOHNSON LIFE CARE, INC
Other - Org Name:JOHNSON LIFE CARE AMBULANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DARREL
Authorized Official - Middle Name:
Authorized Official - Last Name:VANOVER
Authorized Official - Suffix:
Authorized Official - Credentials:EMT
Authorized Official - Phone:606-848-2861
Mailing Address - Street 1:PO BOX 728
Mailing Address - Street 2:
Mailing Address - City:LYNCH
Mailing Address - State:KY
Mailing Address - Zip Code:40855-0728
Mailing Address - Country:US
Mailing Address - Phone:606-848-2861
Mailing Address - Fax:606-848-2409
Practice Address - Street 1:310 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:LYNCH
Practice Address - State:KY
Practice Address - Zip Code:40855
Practice Address - Country:US
Practice Address - Phone:606-848-2861
Practice Address - Fax:606-848-2409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY16093416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY56004179Medicaid
VA010121078Medicaid
KY590011400OtherRAILROAD MEDICARE
KY1416591OtherUNITED MINE WORKERS
KY000000070292OtherBLUE CROSS BLUE SHIELD
KY089589600OtherBLACK LUNG
TN4582350Medicaid
KY50011660OtherPASSPORT HEALTH
KY55048078Medicaid
VA010121078Medicaid