Provider Demographics
NPI: | 1508800780 |
---|---|
Name: | JOHNSON, RICHARD BRIAN (DC) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | RICHARD |
Middle Name: | BRIAN |
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: | 5755 W MAPLE RD |
Mailing Address - Street 2: | SUITE 107 |
Mailing Address - City: | WEST BLOOMFIELD |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 48322-4415 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 248-626-3030 |
Mailing Address - Fax: | 248-626-3455 |
Practice Address - Street 1: | 5755 W MAPLE RD |
Practice Address - Street 2: | SUITE 107 |
Practice Address - City: | WEST BLOOMFIELD |
Practice Address - State: | MI |
Practice Address - Zip Code: | 48322-4415 |
Practice Address - Country: | US |
Practice Address - Phone: | 248-626-3030 |
Practice Address - Fax: | 248-626-3455 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2006-06-16 |
Last Update Date: | 2010-07-13 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | 2301005521 | 111N00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 111N00000X | Chiropractic Providers | Chiropractor |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MI | 116940 | Other | SLECTCARE INSURANCE ID |
MI | 142932577 | Medicaid | |
MI | 950F32961 | Other | BLUE CROSS BLUE SHIELD |
MI | 116940 | Other | SLECTCARE INSURANCE ID |
MI | 142932577 | Medicaid |