Provider Demographics
NPI:1740029792
Name:JOHNSON, COREY DEWITE SR (DIETARY MANAGER)
Entity type:Individual
Prefix:MR
First Name:COREY
Middle Name:DEWITE
Last Name:JOHNSON
Suffix:SR
Gender:M
Credentials:DIETARY MANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7100 E 134TH TER
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:MO
Mailing Address - Zip Code:64030-3357
Mailing Address - Country:US
Mailing Address - Phone:816-215-0334
Mailing Address - Fax:
Practice Address - Street 1:3442 WABASH AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64109-2539
Practice Address - Country:US
Practice Address - Phone:816-215-0334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOJ125035005172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Multi-Specialty