Provider Demographics
NPI:1922698331
Name:JOHNSON, BERNARD THORNTON
Entity Type:Individual
Prefix:MR
First Name:BERNARD
Middle Name:THORNTON
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 72306
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30271-2306
Mailing Address - Country:US
Mailing Address - Phone:678-789-8719
Mailing Address - Fax:470-241-1231
Practice Address - Street 1:15 PERRY ST STE 241
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-1918
Practice Address - Country:US
Practice Address - Phone:678-789-8719
Practice Address - Fax:470-241-1231
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA347C00000X, 344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi
No347C00000XTransportation ServicesPrivate Vehicle