Provider Demographics
NPI:1093840431
Name:JOHNSON, RICHARD LEIF (DC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LEIF
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 1:16460 41ST AVE NO
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446
Mailing Address - Country:US
Mailing Address - Phone:763-550-1499
Mailing Address - Fax:763-550-0443
Practice Address - Street 1:20010 75TH AVENUE NORTH
Practice Address - Street 2:
Practice Address - City:CORCORAN
Practice Address - State:MN
Practice Address - Zip Code:55340
Practice Address - Country:US
Practice Address - Phone:763-416-4878
Practice Address - Fax:763-550-0443
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1172111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN44280J0OtherBLUE CROSS
MN44267J0OtherBLUE CROSS