Provider Demographics
NPI:1043302409
Name:JOHANSEN, RONALD R (DC)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:R
Last Name:JOHANSEN
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 1:12762 SE STARK ST
Mailing Address - Street 2:PLAZA 125 BLDG D
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-1539
Mailing Address - Country:US
Mailing Address - Phone:503-255-7746
Mailing Address - Fax:503-255-0818
Practice Address - Street 1:12762 SE STARK ST
Practice Address - Street 2:PLAZA 125 BLDG D
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1539
Practice Address - Country:US
Practice Address - Phone:503-255-7746
Practice Address - Fax:503-255-0818
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27-1737111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic