1558566588 NPI number — MR. KEVIN CHARLES JOHNSON M.S.

Table of content: MR. KEVIN CHARLES JOHNSON M.S. (NPI 1558566588)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558566588 NPI number — MR. KEVIN CHARLES JOHNSON M.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
KEVIN
Provider Middle Name:
CHARLES
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.S.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558566588
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2731 WETMORE AVE
Provider Second Line Business Mailing Address:
SUITE 208B
Provider Business Mailing Address City Name:
EVERETT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98201-3571
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-303-9309
Provider Business Mailing Address Fax Number:
425-303-9612

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8620 HOLLY DR
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
EVERETT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98208-1825
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-348-4505
Provider Business Practice Location Address Fax Number:
425-348-4538
Provider Enumeration Date:
06/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  LL1063 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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