MEDICARE: BLAKE 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	225100000X	Physical Therapist	304474	CA

General Provider Information

NPI Number	:	1790560969
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BLAKE JOHNSON

Provider Business Mailing Address
First Line	:	380 STEVENS AVE STE 314
Second Line	:
City	:	SOLANA BEACH
State	:	CA
Zip	:	92075-2069
Country	:	US
Telephone Number	:	858-755-5200
Fax Number	:	858-755-5201

Provider Business Practice Location Address
First Line	:	2204 S EL CAMINO REAL STE 225
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92054-6376
Country	:	US
Telephone Number	:	858-755-5200
Fax Number	:	760-826-2525

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

Provider Enumeration Date	:	08/28/2023
Last Update Date	:	09/12/2023

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Directions to “ BLAKE JOHNSON ” Practice Location

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