Provider Demographics
NPI:1053494427
Name:JOHNSON, RICHARD C
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 CANTERBURY DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-2401
Mailing Address - Country:US
Mailing Address - Phone:970-223-4747
Mailing Address - Fax:970-226-1132
Practice Address - Street 1:2600 CANTERBURY DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-2401
Practice Address - Country:US
Practice Address - Phone:970-223-4747
Practice Address - Fax:970-226-1132
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-21
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1266111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC13933Medicare PIN