Provider Demographics
NPI:1255013355
Name:JOHNSON, ZACHARY (COF)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:COF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10671 VETERANS MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-2062
Mailing Address - Country:US
Mailing Address - Phone:770-948-8826
Mailing Address - Fax:
Practice Address - Street 1:10671 VETERANS MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-2062
Practice Address - Country:US
Practice Address - Phone:770-948-8826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAC42048225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter