Healthcare Provider Details

I. General information

NPI: 1992522247
Provider Name (Legal Business Name): MILAN QUISHINA JOHNIGARN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2024
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2116 S CENTRAL AVE
LOS ANGELES CA
90011-1237
US

IV. Provider business mailing address

PO BOX 4262
RIVERSIDE CA
92514-4262
US

V. Phone/Fax

Practice location:
  • Phone: 213-493-4664
  • Fax:
Mailing address:
  • Phone: 951-368-7165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1486991122
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: