Provider Demographics
NPI:1538655345
Name:JOHNSON, NEIL RAYMOND
Entity Type:Individual
Prefix:
First Name:NEIL
Middle Name:RAYMOND
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 1:11549 POKONEN ROAD
Mailing Address - Street 2:
Mailing Address - City:FLOODWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55736
Mailing Address - Country:US
Mailing Address - Phone:218-393-1412
Mailing Address - Fax:
Practice Address - Street 1:11549 POKONEN ROAD
Practice Address - Street 2:
Practice Address - City:FLOODWOOD
Practice Address - State:MN
Practice Address - Zip Code:55736
Practice Address - Country:US
Practice Address - Phone:218-393-1412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-04
Last Update Date:2018-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1082354-1-AFC310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility