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General NPI Number Information
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NPI Number | 1396983888
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Entity Type | Individual
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Provider Name | LARRY WAYNE JOHNSON C.O.
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Gender | Male
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Dates
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Enumeration Date | 01/22/2009
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Last Update Date | 01/22/2009
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Provider Practice Location Address
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Address Line | 9570 RIDGEHAVEN CT SUITE C
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City | SAN DIEGO
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State | CA
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Zip | 92123-1667
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Country | US
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Telephone | 858-278-0518
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Fax | 858-278-0323
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Provider Business Mailing Address
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Address Line | 10723 MONTEGO DR
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City | SAN DIEGO
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State | CA
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Zip | 92124-1910
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Country | US
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Telephone | 858-565-2230
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | CO2834
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License Number State | CA
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