Basic Information
| Provider Information | |||||||||
| NPI: | 1780090761 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RDN, LDN, CEP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | DAN | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RDN, LDN, CEP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | P.O. DRAWER PH | ||||||||
| Address2: | |||||||||
| City: | CHINLE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286747166 | ||||||||
| FaxNumber: | 9286747705 | ||||||||
| Practice Location | |||||||||
| Address1: | IHS PINON HEALTH CENTER NAVAJO RT 4 | ||||||||
| Address2: | |||||||||
| City: | PINON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286747166 | ||||||||
| FaxNumber: | 9286747705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2014 | ||||||||
| LastUpdateDate: | 08/25/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133N00000X | DX3643 | MD | N | Dietary & Nutritional Service Providers | Nutritionist | 133N00000X | 1053031 | CA | N | Dietary & Nutritional Service Providers | Nutritionist | 133V00000X | 1053031 | CA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | DX3643 | MD | N | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.