Healthcare Provider Details

I. General information

NPI: 1598186876
Provider Name (Legal Business Name): JOHNNY KRYNITZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2014
Last Update Date: 01/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12300 FT. MCCLANE ROAD
RADIUM SPRINGS NM
88054
US

IV. Provider business mailing address

PO BOX 385 12300 FT. MCCLANE ROAD
RADIUM SPRINGS NM
88054-0385
US

V. Phone/Fax

Practice location:
  • Phone: 575-635-0559
  • Fax:
Mailing address:
  • Phone: 575-635-0559
  • Fax:

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: