=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336688191
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE JOHNSON FOUNDATION INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2017
-----------------------------------------------------
Last Update Date | 08/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16755 HUGHES RD
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92395-4563
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-684-3419
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14619 MAVERICK PL
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92394-7082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-596-3803
-----------------------------------------------------
Fax | 760-596-3803
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR OF BEHAVIORAL COUNSELING
-----------------------------------------------------
Name | DR. SAMUEL ALEXANDER JOHNSON
-----------------------------------------------------
Credential | DBC
-----------------------------------------------------
Telephone | 760-596-3803
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | J1006181711
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------