Healthcare Provider Details

I. General information

NPI: 1447943998
Provider Name (Legal Business Name): DARYL OLAF JOHNSON LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2023
Last Update Date: 05/31/2023
Certification Date: 05/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 W PRAIRIE AVE
HAYDEN ID
83835-8459
US

IV. Provider business mailing address

827 W PRAIRIE AVE
HAYDEN ID
83835-8459
US

V. Phone/Fax

Practice location:
  • Phone: 208-660-9378
  • Fax: 208-758-8527
Mailing address:
  • Phone: 208-660-9378
  • Fax: 208-758-8527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMAS-3250
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: