Healthcare Provider Details

I. General information

NPI: 1497025951
Provider Name (Legal Business Name): MR. EDWIN DALE JOHNSON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2011
Last Update Date: 12/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

572 N ARROWHEAD AVE STE. 100
SAN BERNARDINO CA
92401-1251
US

IV. Provider business mailing address

572 N ARROWHEAD AVE STE. 100
SAN BERNARDINO CA
92401-1251
US

V. Phone/Fax

Practice location:
  • Phone: 909-266-2700
  • Fax: 909-266-2790
Mailing address:
  • Phone: 909-266-2700
  • Fax: 909-266-2790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: