Individual ProviderLarry Wayne JohnsonSpecialistOther Service ProvidersPractice Address9570 Ridgehaven Ct, Suite C, San Diego, CA 92123-1667(858) 278-0518(858) 565-2230PECOS EnrollmentBased on the most recent information from CMS, provider Larry Wayne Johnson does not have current enrollment records in PECOS.Part BMedicare Part BNot EnrolledHHAHome Health AgencyNot EnrolledDMEDurable Medical EquipmentNot EnrolledPMDPower Mobility DeviceNot EnrolledCMS last updated its PECOS records 2 days ago.Profile DetailsProvider ID1396983888Provider TypeIndividualFull NameJohnson, Larry WayneTitleMr.CredentialC.O.GenderMaleSole ProprietorNoEnumeration Date1/22/2009Last Updated1/22/2009Contact InformationPractice LocationPractice Address9570 Ridgehaven Ct, Suite C, San Diego, CA 92123-1667Phone(858) 278-0518Fax(858) 278-0323Mailing LocationMailing Address10723 Montego Dr, San Diego, CA 92124-1910Phone(858) 565-2230FaxUnlisted FaxProvider TaxonomiesCodeDescriptionLicenseCode174400000XPrimaryDescriptionSpecialistOther Service ProvidersLicenseCO2834California