Provider Demographics
NPI:1891186649
Name:JOHNSON, LARRY WAYNE
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:WAYNE
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 907
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-0907
Mailing Address - Country:US
Mailing Address - Phone:251-410-6474
Mailing Address - Fax:
Practice Address - Street 1:28691 US HIGHWAY 98
Practice Address - Street 2:SUITE D1
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-7195
Practice Address - Country:US
Practice Address - Phone:251-410-6474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-16
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL47-2930554332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies