Provider Demographics
NPI:1154309904
Name:JOHNSON, KEVIN MICHEAL (DC)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:MICHEAL
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 1:2110 S 17TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7408
Mailing Address - Country:US
Mailing Address - Phone:910-343-5250
Mailing Address - Fax:
Practice Address - Street 1:2110 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7408
Practice Address - Country:US
Practice Address - Phone:910-343-5250
Practice Address - Fax:910-343-5299
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3258111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCDB8936OtherRAILROAD MEDICARE PROVIDE
NC085RXOtherBCBS PROVIDER NUMBER
NC085RXOtherBCBS PROVIDER NUMBER