Provider Demographics
NPI:1922129824
Name:JOHNSTON, MARY (RD LD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 W BROAD ST
Mailing Address - Street 2:LOWER LIGHTS CHRISTIAN HEALTH CENTER
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43222-1317
Mailing Address - Country:US
Mailing Address - Phone:614-274-1455
Mailing Address - Fax:614-274-2040
Practice Address - Street 1:1160 W BROAD ST
Practice Address - Street 2:LOWER LIGHTS CHRISTIAN HEALTH CENTER
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43222-1317
Practice Address - Country:US
Practice Address - Phone:614-274-1455
Practice Address - Fax:614-274-2040
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD2555133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHJOMT03581Medicare ID - Type Unspecified