Provider Demographics
NPI:1376934109
Name:JOHNSON CHIROPRACTIC SPORTS & WELLNESS CLINIC, LLC
Entity Type:Organization
Organization Name:JOHNSON CHIROPRACTIC SPORTS & WELLNESS CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:CHAD
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:417-847-0388
Mailing Address - Street 1:907 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CASSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65625-1333
Mailing Address - Country:US
Mailing Address - Phone:417-847-0388
Mailing Address - Fax:417-847-0286
Practice Address - Street 1:907 MAIN ST
Practice Address - Street 2:
Practice Address - City:CASSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65625-1333
Practice Address - Country:US
Practice Address - Phone:417-847-0388
Practice Address - Fax:417-847-0286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-16
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015004021111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty