Provider Demographics
NPI:1649389388
Name:MARY DIANE JOHNSON TMD OUTLET
Entity Type:Organization
Organization Name:MARY DIANE JOHNSON TMD OUTLET
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ABC CERTIFIED FITTER (REM0094
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-588-3404
Mailing Address - Street 1:702 S MONROE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-3570
Mailing Address - Country:US
Mailing Address - Phone:417-588-3404
Mailing Address - Fax:417-588-3404
Practice Address - Street 1:702 S MONROE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-3570
Practice Address - Country:US
Practice Address - Phone:417-588-3404
Practice Address - Fax:417-588-3404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic FitterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO174584OtherBLUE CROSS/BLUE SHIELD
MO=========TMDOtherST. JOHN'S PREMIER INS.
MO=========TMDOtherST. JOHN'S PREMIER INS.