Provider Demographics
NPI:1285648402
Name:JOHNSON, BOB J (DC)
Entity Type:Individual
Prefix:
First Name:BOB
Middle Name:J
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 1:10770 BLACK MOUNTAIN RD SPC 277
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-2951
Mailing Address - Country:US
Mailing Address - Phone:858-863-6419
Mailing Address - Fax:
Practice Address - Street 1:9550 BLACK MOUNTAIN RD STE E
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4577
Practice Address - Country:US
Practice Address - Phone:858-578-5776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17721111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor