Provider Demographics
NPI:1235713165
Name:JOHNSON, ELIJAH (DC)
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:
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 1:1733 PINE CONE RD S
Mailing Address - Street 2:STE 1200
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-5814
Mailing Address - Country:US
Mailing Address - Phone:320-438-4189
Mailing Address - Fax:
Practice Address - Street 1:1733 PINE CONE RD S STE 1200
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-5814
Practice Address - Country:US
Practice Address - Phone:320-217-2542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-06
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6856111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor