Provider Demographics
NPI:1518316272
Name:JOHNSON FAMILY CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:JOHNSON FAMILY CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:405-752-8819
Mailing Address - Street 1:11914 N PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE B3
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-7831
Mailing Address - Country:US
Mailing Address - Phone:405-752-8819
Mailing Address - Fax:405-751-1238
Practice Address - Street 1:11914 N PENNSYLVANIA AVE
Practice Address - Street 2:SUITE B3
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-7831
Practice Address - Country:US
Practice Address - Phone:405-752-8819
Practice Address - Fax:405-751-1238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2626305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK245712201Medicare PIN