Basic Information
| Provider Information | |||||||||
| NPI: | 1225624687 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | JOHNNY | ||||||||
| MiddleName: | MARVIN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3465 NIBLICK DR | ||||||||
| Address2: | |||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919418054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6193064858 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 880 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919111305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196624100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2020 | ||||||||
| LastUpdateDate: | 12/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | OTA3785 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.