Provider Demographics
NPI:1558547026
Name:JOHNSON CHIROPRACTIC HEALTH SERVICE
Entity Type:Organization
Organization Name:JOHNSON CHIROPRACTIC HEALTH SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:NEIL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-921-4910
Mailing Address - Street 1:195 14TH ST
Mailing Address - Street 2:P.O.BOX 1451
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-5976
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:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1431261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000070355Medicare PIN