Individual
MR. COREY DEWITE JOHNSON SR.
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DIETARY MANAGER
Contact information
Practice address
3442 WABASH AVE, KANSAS CITY, MO 64109-2539
(816) 215-0334
Mailing address
7100 E 134TH TER, GRANDVIEW, MO 64030-3357
(816) 215-0334
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
J125035005
MO
Other
Enumeration date
05/20/2024
Last updated
05/20/2024
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