Provider Demographics
NPI:1780417238
Name:GAINES, JOHNNNY M
Entity type:Individual
Prefix:
First Name:JOHNNNY
Middle Name:M
Last Name:GAINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13283 SYRACUSE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48212-2419
Mailing Address - Country:US
Mailing Address - Phone:313-330-2988
Mailing Address - Fax:
Practice Address - Street 1:13283 SYRACUSE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48212
Practice Address - Country:US
Practice Address - Phone:313-330-2988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-21
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health