Provider Demographics
NPI:1710704630
Name:ROYAL, JUSTIN JOHNSON
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:JOHNSON
Last Name:ROYAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 MADISON HEIGHTS SQ
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:24572-6243
Mailing Address - Country:US
Mailing Address - Phone:434-846-8288
Mailing Address - Fax:434-846-5691
Practice Address - Street 1:197 MADISON HEIGHTS SQ
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:24572-6243
Practice Address - Country:US
Practice Address - Phone:434-846-8288
Practice Address - Fax:434-846-5691
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101004417156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician