Healthcare Provider Details

I. General information

NPI: 1477478501
Provider Name (Legal Business Name): RICKY JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4880 SW 5TH ST APT 2100
LINCOLN NE
68523-9539
US

IV. Provider business mailing address

3511 N 22ND ST
OMAHA NE
68110-1869
US

V. Phone/Fax

Practice location:
  • Phone: 281-386-0405
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberH14084645
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: