Provider Demographics
NPI:1043380512
Name:JOHNSTON, RAYMOND MARC (DC, QME)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:MARC
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:DC, QME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2914
Mailing Address - Country:US
Mailing Address - Phone:805-541-2727
Mailing Address - Fax:805-541-2729
Practice Address - Street 1:1150 GROVE ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2914
Practice Address - Country:US
Practice Address - Phone:805-541-2727
Practice Address - Fax:805-541-2729
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC11453111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWDC11453AOtherOTHER STATE IDENTIFIER
CADC11453OtherSTATE LICENSE
CADC11453OtherSTATE LICENSE
CAWDC11453AOtherOTHER STATE IDENTIFIER
CAWDC6639Medicare ID - Type UnspecifiedMEDICARE GROUP