Healthcare Provider Details

I. General information

NPI: 1639147697
Provider Name (Legal Business Name): WAYNE CARLETON JOHNSON IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL HOSPITAL BOX 788250
TWENTYNINE PALMS CA
92278-8250
US

IV. Provider business mailing address

3848B WESTSIDE RD
TWENTYNINE PALMS CA
92277-9407
US

V. Phone/Fax

Practice location:
  • Phone: 760-830-2677
  • Fax: 760-830-2601
Mailing address:
  • Phone: 760-368-2149
  • Fax: 760-830-2601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: