Healthcare Provider Details

I. General information

NPI: 1417765116
Provider Name (Legal Business Name): MR. RALFIKI JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2024
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20846 BAKAL DR
RIVERSIDE CA
92508-2983
US

IV. Provider business mailing address

19510 VAN BUREN BLVD # F3-123
RIVERSIDE CA
92508-9457
US

V. Phone/Fax

Practice location:
  • Phone: 951-283-2910
  • Fax:
Mailing address:
  • Phone: 951-283-2910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: