Organization
MARY DIANE JOHNSON TMD OUTLET
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. MARY D JOHNSON (OWNER/ABC CERTIFIED FITTER (REM0094)
(417) 588-3404
Entity
Organization
Contact information
Practice address
702 S MONROE, LEBANON, MO 65536-3570
(417) 588-3404
(417) 588-3404
Mailing address
702 S MONROE, LEBANON, MO 65536-3570
(417) 588-3404
(417) 588-3404
Taxonomy
Speciality
Code
Description
License number
State
225000000X
Orthotic Fitter
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
174584
BLUE CROSS/BLUE SHIELD
MO
Enumeration date
08/29/2006
Last updated
06/16/2008
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