Provider Demographics
NPI:1275974545
Name:JOHNSON CHIROPRACTIC, SC
Entity Type:Organization
Organization Name:JOHNSON CHIROPRACTIC, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-808-1123
Mailing Address - Street 1:310 SUSAN DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-6246
Mailing Address - Country:US
Mailing Address - Phone:309-808-1123
Mailing Address - Fax:309-808-1516
Practice Address - Street 1:310 SUSAN DR
Practice Address - Street 2:SUITE 2
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6246
Practice Address - Country:US
Practice Address - Phone:309-808-1123
Practice Address - Fax:309-808-1516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-15
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011514261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center