Healthcare Provider Details

I. General information

NPI: 1932874187
Provider Name (Legal Business Name): ELI B. JOHNSON CSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 E AZTEC AVE
GALLUP NM
87301-4803
US

IV. Provider business mailing address

2025 E AZTEC AVE
GALLUP NM
87301-4803
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-3828
  • Fax: 505-863-6612
Mailing address:
  • Phone: 505-863-3828
  • Fax: 505-863-6612

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: