MEDICARE: MR. RICKY C JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1073050134
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICKY C JOHNSON

Provider Business Mailing Address
First Line	:	1200 S TORREY PINES DR
Second Line	:	APT 156
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-1013
Country	:	US
Telephone Number	:	702-769-2313
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 S TORREY PINES DR
Second Line	:	APT 156
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-1013
Country	:	US
Telephone Number	:	702-769-2313
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/27/2017
Last Update Date	:	01/27/2017

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Directions to “ MR. RICKY C JOHNSON ” Practice Location

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