1770004764 NPI number — GREGORY NATHAN JOHNSON PT, DPT

Table of content: GREGORY NATHAN JOHNSON PT, DPT (NPI 1770004764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770004764 NPI number — GREGORY NATHAN JOHNSON PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
GREGORY
Provider Middle Name:
NATHAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
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:
1770004764
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/29/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5718
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KALISPELL
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59903-5718
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-756-0134
Provider Business Mailing Address Fax Number:
406-309-2579

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 E IDAHO ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KALISPELL
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59901-4117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-756-7878
Provider Business Practice Location Address Fax Number:
406-257-7811
Provider Enumeration Date:
06/29/2017

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: 225100000X , with the licence number:  13000 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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