Individual
WILLIE JOHNSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
GM
Contact information
Practice address
108 JULIE LN, AUBURNDALE, FL 33823-2335
(863) 269-8897
Mailing address
23781 HWY 27 # 226, LAKE WALES, FL 33859-7802
(863) 269-8897
Taxonomy
Speciality
Code
Description
License number
State
332BC3200X
Customized Equipment (DME)
Primary
207683
FL
332BP3500X
Parenteral & Enteral Nutrition Supplies (DME)
207693
FL
Other
Enumeration date
09/09/2022
Last updated
09/09/2022
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