Provider Demographics
NPI:1407910029
Name:JOHNS, ELGIN BRUCE JR (SPN PHYSICIAN EXTEND)
Entity Type:Individual
Prefix:
First Name:ELGIN
Middle Name:BRUCE
Last Name:JOHNS
Suffix:JR
Gender:M
Credentials:SPN PHYSICIAN EXTEND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 WILLMAR AVE SW
Mailing Address - Street 2:ACMC
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201
Mailing Address - Country:US
Mailing Address - Phone:320-231-5000
Mailing Address - Fax:320-231-5067
Practice Address - Street 1:101 WILLMAR AVE SW
Practice Address - Street 2:AFFILIATED COMMUNITY MEDICAL CENTERS
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201
Practice Address - Country:US
Practice Address - Phone:320-231-5000
Practice Address - Fax:320-231-5067
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL0354989164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse