Healthcare Provider Details

I. General information

NPI: 1366738411
Provider Name (Legal Business Name): MR. DARAYON DAVON JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 06/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2349 RENAISSANCE DR SUITE A
LAS VEGAS NV
89119-6191
US

IV. Provider business mailing address

6236 DIAZO ST
NORTH LAS VEGAS NV
89031-1727
US

V. Phone/Fax

Practice location:
  • Phone: 702-739-7716
  • Fax:
Mailing address:
  • Phone: 702-376-7914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: