Provider Demographics
NPI:1932464443
Name:JOHNSON, EARVIN
Entity Type:Individual
Prefix:
First Name:EARVIN
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 1:4370 S GRAND CANYON DR
Mailing Address - Street 2:APT 1043
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-7107
Mailing Address - Country:US
Mailing Address - Phone:702-347-0957
Mailing Address - Fax:
Practice Address - Street 1:4370 S GRAND CANYON DR
Practice Address - Street 2:APT 1043
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-7107
Practice Address - Country:US
Practice Address - Phone:702-347-0957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-10
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty