Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 10509 | CO |
NPI | 1003121690 |
---|---|
Provider Name | Justin Johnson |
First Address | Colorado Springs, CO 80903-5912 |
Second Address | Farmington Hills, MI 48331-5716 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/08/2010 |
Last Update Date | 09/08/2010 |