Provider Demographics
NPI:1023360633
Name:JOHNSON, KRAIG LEE
Entity Type:Individual
Prefix:MR
First Name:KRAIG
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81840 AVENUE 46 STE 201
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-3948
Mailing Address - Country:US
Mailing Address - Phone:760-391-6999
Mailing Address - Fax:760-391-6998
Practice Address - Street 1:81840 AVENUE 46 STE 201
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-3948
Practice Address - Country:US
Practice Address - Phone:760-391-6999
Practice Address - Fax:760-391-6998
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-05
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator