Provider Demographics
NPI:1912313842
Name:RYAN JOHNSON
Entity type:Organization
Organization Name:RYAN JOHNSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:619-961-9130
Mailing Address - Street 1:4190 BONITA RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-1329
Mailing Address - Country:US
Mailing Address - Phone:619-961-9130
Mailing Address - Fax:619-916-2120
Practice Address - Street 1:4190 BONITA RD
Practice Address - Street 2:SUITE 104
Practice Address - City:BONITA
Practice Address - State:CA
Practice Address - Zip Code:91902-1329
Practice Address - Country:US
Practice Address - Phone:619-961-9130
Practice Address - Fax:619-916-2120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-11
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU2900237600000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty