Provider Demographics
NPI:1063631497
Name:JOHNSON, BRUCE ROB (DC)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ROB
Last Name:JOHNSON
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 1:4101 MAIN STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29926
Mailing Address - Country:US
Mailing Address - Phone:843-342-3606
Mailing Address - Fax:843-342-3608
Practice Address - Street 1:4101 MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29926-4608
Practice Address - Country:US
Practice Address - Phone:843-342-3606
Practice Address - Fax:843-342-3608
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2682111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA30680281Medicare PIN
SCU81892Medicare UPIN