Provider Demographics
NPI:1164620613
Name:JOHNSON CHIROPRACTIC CLINIC OF MAPLE GROVE, INC
Entity Type:Organization
Organization Name:JOHNSON CHIROPRACTIC CLINIC OF MAPLE GROVE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-420-4242
Mailing Address - Street 1:13700 83RD WAY N STE 200
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7015
Mailing Address - Country:US
Mailing Address - Phone:763-420-4242
Mailing Address - Fax:
Practice Address - Street 1:13700 83RD WAY N STE 200
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7015
Practice Address - Country:US
Practice Address - Phone:763-420-4242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1844111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNT39653Medicare UPIN