Healthcare Provider Details

I. General information

NPI: 1912313842
Provider Name (Legal Business Name): RYAN JOHNSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2014
Last Update Date: 05/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4190 BONITA RD SUITE 104
BONITA CA
91902-1329
US

IV. Provider business mailing address

4190 BONITA RD SUITE 104
BONITA CA
91902-1329
US

V. Phone/Fax

Practice location:
  • Phone: 619-961-9130
  • Fax: 619-916-2120
Mailing address:
  • Phone: 619-961-9130
  • Fax: 619-916-2120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAU2900
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberAU2900
License Number StateCA

VIII. Authorized Official

Name: DR. RYAN JOHNSON
Title or Position: OWNER
Credential: AU.D.
Phone: 619-961-9130