Provider Demographics
NPI:1043823461
Name:JOHNSON, CRYSTAL D
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10736 JEFFERSON BLVD # 775
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-4933
Mailing Address - Country:US
Mailing Address - Phone:310-428-8309
Mailing Address - Fax:
Practice Address - Street 1:11140 JEFFERSON BLVD STE 7
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-5522
Practice Address - Country:US
Practice Address - Phone:310-428-8309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2022-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No1744P3200XOther Service ProvidersSpecialistProsthetics Case Management