Provider Demographics
NPI:1346567492
Name:JOHNSON CHIROPRACTIC HEALTH CENTER, SC
Entity Type:Organization
Organization Name:JOHNSON CHIROPRACTIC HEALTH CENTER, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRET
Authorized Official - Middle Name:Z
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-921-4910
Mailing Address - Street 1:PO BOX 1451
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54936-1451
Mailing Address - Country:US
Mailing Address - Phone:920-921-4910
Mailing Address - Fax:920-921-8645
Practice Address - Street 1:195 14TH ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-5976
Practice Address - Country:US
Practice Address - Phone:920-921-4910
Practice Address - Fax:920-921-8645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-29
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4292-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000035948Medicare PIN
WIV11755Medicare UPIN