Healthcare Provider Details

I. General information

NPI: 1669879136
Provider Name (Legal Business Name): ROYA T JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2014
Last Update Date: 12/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1507 1/4 12TH AVE
LOS ANGELES CA
90019-4319
US

IV. Provider business mailing address

1507 1/4 12TH AVE
LOS ANGELES CA
90019-4319
US

V. Phone/Fax

Practice location:
  • Phone: 323-308-5685
  • Fax:
Mailing address:
  • Phone: 323-308-5685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: