Provider Demographics
NPI:1669840740
Name:WATKINS, JOHNNY JR (DPT)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:WATKINS
Suffix:JR
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6542 RUSTIC RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-4956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6012 SOUTH LINDEN ROAD
Practice Address - Street 2:UNIT 15 MONTICELLO CENTER
Practice Address - City:SWARTZ CREEK
Practice Address - State:MI
Practice Address - Zip Code:48473-8889
Practice Address - Country:US
Practice Address - Phone:810-655-8244
Practice Address - Fax:810-655-2192
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-08
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017308225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist