Provider Demographics
NPI:1073050134
Name:JOHNSON, RICKY C
Entity Type:Individual
Prefix:MR
First Name:RICKY
Middle Name:C
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 1:1200 S TORREY PINES DR
Mailing Address - Street 2:APT 156
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-1013
Mailing Address - Country:US
Mailing Address - Phone:702-769-2313
Mailing Address - Fax:
Practice Address - Street 1:1200 S TORREY PINES DR
Practice Address - Street 2:APT 156
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-1013
Practice Address - Country:US
Practice Address - Phone:702-769-2313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-27
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health