Healthcare Provider Details

I. General information

NPI: 1104792118
Provider Name (Legal Business Name): RAEMELL CHERROD JOHNSON LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2025
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

989 KENMORE AVE
KENMORE NY
14217-2924
US

IV. Provider business mailing address

147 DEERFIELD AVE
BUFFALO NY
14215-3024
US

V. Phone/Fax

Practice location:
  • Phone: 716-335-9711
  • Fax:
Mailing address:
  • Phone: 716-482-2028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number034052
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: