Provider Demographics
NPI:1366934440
Name:JOHNSON, BENJAMIN HENNING
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:HENNING
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5345 S 4550 W
Mailing Address - Street 2:
Mailing Address - City:HOOPER
Mailing Address - State:UT
Mailing Address - Zip Code:84315-6710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:875 PERIMETER DR # MS 2401
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83844-9803
Practice Address - Country:US
Practice Address - Phone:801-710-0760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer