Provider Demographics
NPI:1134630957
Name:JOHNSON, EDDIE
Entity type:Individual
Prefix:
First Name:EDDIE
Middle Name:
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 124
Mailing Address - Street 2:
Mailing Address - City:LONE STAR
Mailing Address - State:TX
Mailing Address - Zip Code:75668-0124
Mailing Address - Country:US
Mailing Address - Phone:903-646-3171
Mailing Address - Fax:
Practice Address - Street 1:338 BOND ST
Practice Address - Street 2:
Practice Address - City:LONE STAR
Practice Address - State:TX
Practice Address - Zip Code:75668-0230
Practice Address - Country:US
Practice Address - Phone:903-646-3171
Practice Address - Fax:903-646-0512
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities