Basic Information
| Provider Information | |||||||||
| NPI: | 1700061728 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | EARL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11704 DECLARATION DR | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917308225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099899221 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2990 INLAND EMPIRE BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917644899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262545000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2008 | ||||||||
| LastUpdateDate: | 01/09/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.