Healthcare Provider Details

I. General information

NPI: 1245028877
Provider Name (Legal Business Name): SANDRA JOHNSON PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2025
Last Update Date: 04/25/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 RESPONSE RD STE 350
SACRAMENTO CA
95815-5255
US

IV. Provider business mailing address

1651 RESPONSE RD STE 350
SACRAMENTO CA
95815-5255
US

V. Phone/Fax

Practice location:
  • Phone: 916-573-1372
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MABEL POWERS
Title or Position: ADMINISTRATOR
Credential:
Phone: 916-238-8945