Provider Demographics
NPI:1790163806
Name:JOHNSTON OCULAR PROSTHETICS, INC
Entity Type:Organization
Organization Name:JOHNSTON OCULAR PROSTHETICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:C
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:BCO, BADO
Authorized Official - Phone:919-207-2515
Mailing Address - Street 1:7476 OLD FAIRGROUND RD
Mailing Address - Street 2:
Mailing Address - City:BENSON
Mailing Address - State:NC
Mailing Address - Zip Code:27504-6105
Mailing Address - Country:US
Mailing Address - Phone:919-207-2515
Mailing Address - Fax:919-894-1335
Practice Address - Street 1:7476 OLD FAIRGROUND RD
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:NC
Practice Address - Zip Code:27504-6105
Practice Address - Country:US
Practice Address - Phone:919-207-2515
Practice Address - Fax:919-894-1335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-08
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNONE332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC332BC3200XMedicaid
NC1831255561Medicare PIN