Provider Demographics
NPI:1952916231
Name:JOHNSON, CHADRIKA L (OWNER, CENTER DIRECT)
Entity Type:Individual
Prefix:
First Name:CHADRIKA
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OWNER, CENTER DIRECT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 ALTAMA CONNECTOR UNIT 181
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525-1888
Mailing Address - Country:US
Mailing Address - Phone:912-571-7497
Mailing Address - Fax:
Practice Address - Street 1:1800 ALBANY ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-5901
Practice Address - Country:US
Practice Address - Phone:912-571-7497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-13
Last Update Date:2020-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA9125717497OtherN/A AT THIS TIME, CONTACT NUMBER