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Individual

LARRY JOHNSON SR.

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
Man

Contact information

Practice address
600 LAKE AIR DR, SUITE 3A, WACO, TX 76710-5887
(254) 224-6208
Mailing address
600 LAKE AIR DR, SUITE 3A, WACO, TX 76710-5887
(254) 224-6208

Taxonomy

Speciality
Code
Description
License number
State
347C00000X
Private Vehicle
Primary
36634675
TX

Other

Enumeration date
01/07/2015
Last updated
01/07/2015
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