Healthcare Provider Details

I. General information

NPI: 1801584388
Provider Name (Legal Business Name): PASCAL ROQUE JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: PASCAL ROQUE JOHNSON

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 12/19/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 CRENSHAW BLVD STE 215
LOS ANGELES CA
90043-1200
US

IV. Provider business mailing address

3860 CRENSHAW BLVD STE 201
LOS ANGELES CA
90008-1816
US

V. Phone/Fax

Practice location:
  • Phone: 323-291-7100
  • Fax:
Mailing address:
  • Phone: 323-593-5300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: