Provider Demographics
NPI:1124180450
Name:JOHNSON, RANDY ROBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:ROBERT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1706 EAST TENTH STREET
Mailing Address - Street 2:GAUER CHIROPRACTIC CLINIC
Mailing Address - City:GLENCOE
Mailing Address - State:MN
Mailing Address - Zip Code:55336
Mailing Address - Country:US
Mailing Address - Phone:320-864-3196
Mailing Address - Fax:320-864-3197
Practice Address - Street 1:1706 EAST TENTH STREET
Practice Address - Street 2:GAUER CHIROPRACTIC CLINIC
Practice Address - City:GLENCOE
Practice Address - State:MN
Practice Address - Zip Code:55336
Practice Address - Country:US
Practice Address - Phone:320-864-3196
Practice Address - Fax:320-864-3197
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4635111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
30701128OtherPRIME WEST
MN869035OtherAMERICAS PPO
MN649104OtherCHIROPRACTIC CARE OF MINN
MN370K6J0OtherBCBS
MN649104OtherCHIROPRACTIC CARE OF MINN