Provider Demographics
NPI:1629690920
Name:JOHNSON, VINCENT VAN
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:VAN
Last Name:JOHNSON
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:PO BOX 560021
Mailing Address - Street 2:
Mailing Address - City:MACEDONIA
Mailing Address - State:OH
Mailing Address - Zip Code:44056-0021
Mailing Address - Country:US
Mailing Address - Phone:216-303-9900
Mailing Address - Fax:844-823-3046
Practice Address - Street 1:17325 EUCLID AVE STE 4028
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44112-1270
Practice Address - Country:US
Practice Address - Phone:216-303-9900
Practice Address - Fax:844-823-3046
Is Sole Proprietor?:No
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator