Provider Demographics
NPI:1285674101
Name:JOHNSON, KENNETH G (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:G
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 1:12280 LINCOLN HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:NORTH HUNTINGDON
Mailing Address - State:PA
Mailing Address - Zip Code:15642
Mailing Address - Country:US
Mailing Address - Phone:724-864-7447
Mailing Address - Fax:724-864-8022
Practice Address - Street 1:12280 LINCOLN HIGHWAY
Practice Address - Street 2:
Practice Address - City:NORTH HUNTINGDON
Practice Address - State:PA
Practice Address - Zip Code:15642
Practice Address - Country:US
Practice Address - Phone:724-864-7447
Practice Address - Fax:724-864-8022
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC003370L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T26836Medicare UPIN
PA164966Medicare ID - Type Unspecified