Provider Demographics
NPI:1003084989
Name:CLEMANS, JOHNNIE R (DC)
Entity Type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:R
Last Name:CLEMANS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7805 USTICK RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5849
Mailing Address - Country:US
Mailing Address - Phone:208-375-7851
Mailing Address - Fax:208-375-1905
Practice Address - Street 1:7805 USTICK RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5849
Practice Address - Country:US
Practice Address - Phone:208-375-7851
Practice Address - Fax:208-375-1905
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA0610111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDU20591Medicare UPIN