MEDICARE: PRESTON JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1023784576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PRESTON JOHNSON

Provider Business Mailing Address
First Line	:	1734 XIMENO AVE APT 4
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90815-3751
Country	:	US
Telephone Number	:	760-550-4403
Fax Number	:

Provider Business Practice Location Address
First Line	:	1734 XIMENO AVE APT 4
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90815-3751
Country	:	US
Telephone Number	:	760-550-4403
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2021
Last Update Date	:	08/16/2021

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Directions to “ PRESTON JOHNSON ” Practice Location

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