Provider Demographics
NPI:1639750326
Name:JOHNSON, DANE GEORGE (DPT)
Entity Type:Individual
Prefix:DR
First Name:DANE
Middle Name:GEORGE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11068 SHILOH CT
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-7810
Mailing Address - Country:US
Mailing Address - Phone:909-767-2843
Mailing Address - Fax:
Practice Address - Street 1:400 N MOUNTAIN AVE STE 310
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-5182
Practice Address - Country:US
Practice Address - Phone:909-920-6457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist