Provider Demographics
NPI:1083085369
Name:JOHNSON, GARY
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
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 1:1539 W AVENUE L12
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-6930
Mailing Address - Country:US
Mailing Address - Phone:661-948-1275
Mailing Address - Fax:661-902-6985
Practice Address - Street 1:1539 W AVENUE L12
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-6930
Practice Address - Country:US
Practice Address - Phone:661-948-1275
Practice Address - Fax:661-902-6985
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA197605271310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility