Provider Demographics
NPI:1598275752
Name:JOHNSTON, BRYCE WILLIAM (DC)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:WILLIAM
Last Name:JOHNSTON
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 1:175 OLD HIGHWAY 36
Mailing Address - Street 2:
Mailing Address - City:CLARENCE
Mailing Address - State:MO
Mailing Address - Zip Code:63437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:119 W CHESTNUT
Practice Address - Street 2:
Practice Address - City:CLARENCE
Practice Address - State:MO
Practice Address - Zip Code:63437
Practice Address - Country:US
Practice Address - Phone:660-699-2233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017034995111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty